Uniformity and diversity of calcium metabolism in hypertension. A conceptual framework

Association between metabolic syndrome components and the risk of developing nephrolithiasis: A systematic review and bayesian meta-analysis

Background: There is increasing evidence that nephrolithiasis is a systemic disease, as opposed to an isolated urinary metabolic problem, after considerable links were found between nephrolithiasis and systemic diseases such as hypertension, obesity, dyslipidemia, and insulin resistance. The interplay between these four factors defines metabolic syndrome (MetS). In this review we aim to clarify the associations of MetS and its components to kidney stone incident. Methods: Online databases of EMBASE, MEDLINE, and Google Scholar were searched from January 1998 up to October 2020 to identify observational studies examining the association between metabolic syndrome components and kidney stone incident. Bayesian random-effects meta-analysis and meta-regression were performed to observe the association. Linear dose-response analysis was conducted to shape the direction of the association. Data analysis was performed using STATA, and R statistics. Results: A total of 25 potentially relevant studies (n = 934,588 participants) were eventually identified. The pooled results suggested that metabolic syndrome was associated with an increased risk of nephrolithiasis with an odds ratio (OR) of 1.769 (95% CI: 1.386 - 2.309).  The summary OR of hypertension and dyslipidemia for developing nephrolithiasis were 1.613 (95% CI: 1.213 - 2.169) and 1.586 (95% CI: 1.007 - 2.502) respectively. The presence of diabetes mellitus and obesity had an OR of 1.552 (95% CI: 1.027 - 2.344) and 1.531 (95% CI: 1.099 - 2.109) respectively. Our results revealed that the increasing number of MetS traits will increase the risk of developing nephrolithiasis, the higher the fasting plasma glucose, and body mass index, the higher the risk of kidney stones incident. Conclusions: Our results suggest that hypertension, diabetes, obesity and dyslipidemia are associated with increased risk of developing nephrolithiasis. Linear significant association between MetS components and nephrolithiasis were revealed in our study which reinforced the notion that should be considered a systemic disorder.

25-Hydroxyvitamin D is associated with plasma renin activity and the pressor response to dietary sodium intake in Caucasians

INTRODUCTION

Concentrations of 1,25-hydroxyvitamin D have been positively associated with dietary sodium and salt sensitivity (SS) of blood pressure (BP), and inversely with plasma renin activity (PRA). We investigated the association between PRA and 25-hydroxyvitamin D (25OHD), the most clinically relevant vitamin D metabolite, and whether 25OHD associates with SS of BP in renin phenotypes of hypertension.

METHODS

We performed cross-sectional analyses on 223 Caucasian subjects with hypertension maintained in high and low dietary sodium balance. Subjects were distinguished as having low-renin (LR) or normal-renin (NR) hypertension. Multivariable linear regression was used to evaluate adjusted relationships.

RESULTS

Increasing 25OHD concentrations were inversely associated with PRA (p < 0.05) on both salt diets. Furthermore, 25OHD was associated with SS of BP in LR hypertension (b = 0.62, p = 0.04), but not in NR hypertension (b = 0.06, p = 0.59). In an adjusted multivariable interaction model, renin status (LR vs. NR) was a significant effect modifier of the relationship between 25OHD and SS of BP (p = 0.04).

CONCLUSIONS

Our findings suggest that 25OHD is inversely associated with PRA and positively associated with SS of BP in LR hypertension subjects. These results extend and support prior evidence indicating an interaction between dietary sodium, the RAS, and vitamin D that influences BP in hypertension.

Vaso-active factors in pregnancy

Pregnancy results in profound physiological changes in the cardiovascular system, yet these changes are completely reversible. It is apparent that vaso-active factors, some as yet probably unidentified, which act as humoral or local autocrine or paracrine regulators of vasular resistance, play a major role in these cardio-vascular changes. This role may be heightened in pregnancy when there has to be a large increase in blood flow to the uterus and placenta while maintaining adequate flow to other vascular beds. Our knowledge of the mechanisms of action of these vaso-active factors and their interactions with each other still remains incomplete. Alterations in synthesis and action of these vaso-active factors may occur in pregnancies associated with pregnancy-induced hypertension, pre-eclampsia or intra-uterine growth retardation. Investigation of such alterations may help to elucidate the roles of vaso-active factors in both normal and pathological situations. The gestational hormones oestrogen and progesterone, are obviously prime candidates as overall regulators of the cardiovascular changes of pregnancy and as agents which alter the synthesis or action of other vaso-active factors. Currently, much attention is being focused on the role of local autocrine or paracrine vaso-active factors which may be produced by the endothelium or by the underlying vascular smooth muscle cells and alterations in their production or action in the hyptertensive disorders of pregnancy. The endothelium forms the largest endocrine organ within the body and so its importance in the mediation of vascular events should not be under-estimated. The principal objective of this review is to examine the roles of these many autocrine and paracrine vaso-active factors during pregnancy and their relation with the overall regulation of the vascular system. Changes which may occur and be involved in the aetiology of pre-eclampsia and growth retardation will also be examined.

Effect of Dietary Calcium Supplements and Amlodipine on Growth, Arterial Blood Pressure, and Cardiac Hypertrophy of Spontaneously Hypertensive Rats

It has been shown that calcium-enriched diets cause a decrease in arterial blood pressure in hypertensive patients and animals. Moreover, it has been suggested that the combination of dietary calcium and calcium antagonists could paradoxically have a synergistic effect in order to decrease arterial blood pressure. The combination of these treatments may also have potential therapeutic benefit in the attenuation of cardiac hypertrophy. In this study, after being weaned at three weeks, male spontaneously hypertensive rats (SHR) were randomized in four groups of animals. Two of these groups were fed on a normal calcium diet (Ca 1%) and another two groups were fed on a calcium-enriched diet (Ca 2.5%). One of the groups fed on each diet also received amlodipine (1 mg/kg/day) in the drinking water after being weaned. Body weight was measured weekly in all the groups, and arterial blood pressure was also measured in all the 10-, 15-, 20-, and 25-week-old SHR by the tail cuff method. We established the ratio heart weight/body weight x 1000 (R), and we weighed the left ventricle in the 25-week-old animals at the end of the different treatments. The Ca 2.5% diet caused a delay in the development of hypertension in SHR. This effect could not be correlated with alterations in body weight since this diet improved growth in these rats. Amlodipine did not alter growth in SHR. This pharmacological treatment caused a decrease in the arterial blood pressure of the SHR and it intensified the antihypertensive effect of the Ca 2.5% diet. Nevertheless, this drug attenuated the effect of dietary calcium on body weight and when the treatment was prolonged, almodipine also antagonized the effect of dietary calcium on arterial blood pressure. At the end of the different treatments the ratio R and the left ventricular weight were similar in all the groups of animals. Therefore, the use of dietary calcium with a calcium antagonist to control arterial blood pressure seems not to be advisable, and the present data do not prove the usefulness of the mentioned antihypertensive treatments in preventing cardiac hypertrophy.

[Changes in calcium levels in blood and urine during various regimens of table salt intake in patients with essential arterial hypertension]

INTRODUCTION

It has been reported that changes in salt loading influence parameters of calcium metabolism in hypertensive subjects. It was also reported that response of blood pressure to salt intake is related to salt-induced increase in intracellular calcium and decrease in intracellular magnesium concentrations [1]. Several authors showed that salt-sensitive hypertensive subjects significantly decreased blood pressure after calcium intake which was emphasized by high salt intake. Resnick et al. showed that during high salt intake regimen increase in blood pressure was followed with decrease in serum calcium level, this was explained by the fact that high salt intake stimulates the calcium uptake by cells [2]. They also reported the following characteristics of hypertensive patients with additionally lower blood pressure as a response to calcium intake: salt-sensitive, low serum ionized calcium and plasma renin activity (PRA) values and high parathyroid hormonE (PTH) values and 1.25-(OH)2-D values. The aim of the study was to evaluate values of corrected and ionized serum and urine calcium in a group of salt-sensitive patients, salt-resistant patients and a whole group during normal salt-intake regimen, and a group without salt and during sodium load (10 g salt extra).

MATERIAL AND METHODS

In our study, 50 untreated patients (27 women and 23 men; average age 42 +/- 9.2 yrs; average BMI 27.91 +/- 4.6 kg/m2) with essential hypertension were put on a high salt regimen (200 mmol NaCl per day) for one week after a week on a low salt diet (20 mmol NaCl per day). On the last day of the normal regimen and during the 1st, 3rd and 5th day of low salt and high salt regimens, the following follow-up was carried out: total (corrected) serum calcium level and total urine calcium level, ionized serum calcium urine creatininE level; serum albumin and daily diuresis and blood pressure. All patients had normal sodium and potassium serum concentrations. Salt intake was checked by taking a specimen of 24-hour urine considered as satisfactory if sodium excretion of 100 to 150 mmol/d (mmol per day) was noted. During the whole hospital examination, calcium intake through hospital meals was standardized to about 817 mg of calcium daily. Salt sensitivity was defined as 10 mmHg increase in mean blood pressure at the end of high vs. low salt diet. Salt sensitive group consisted of 26 patients and salt insensitive of 24 patients.

RESULTS

According to sex, there was no statistically significant difference: 27 females (54%) and 24 males (46%). Average age of patients was 49 +/- 9.2 yrs, ranging from 21 to 64 with normal frequency distribution. Average body weight was 80.49 kg +/- 12.45 kg. Body height was from 150 to 192 cm with average of 170.12 +/- 10.53 cm. Average value of Body Mass Index (BMI in kg per square meter) was 27.91 +/- 4.6. In the studied patients average duration of hypertension was 6.98 +/- 6.4 yrs with non-homogeneous distribution. In 32 patients (64%) the medical history confirmed that one or more family members had hypertension. It was found that salt loading significantly decreased ionized calcium (F = 2.49; p < 0.05) and significantly increased urinary excretion of calcium (F = 5.22; p < 0.001) in salt sensitive patients in comparison with salt insensitive subjects. Serum calcium did not differ significantly during different salt intake regimens between two groups. Our study revealed no positive correlation between gender, age, BMI and family history and calcium metabolism.

CONCLUSION

The findings of this study support the opinion of altered calcium metabolism in hypertensive subjects sensitive to salt intake. By demonstrated results we tried to define clinically different pathophysiologic and potentially different therapeutic subgroups in hypertensive population and to point to clinical and biochemical heterogeneity of primary hypertension.

HCaRG, a novel calcium-regulated gene coding for a nuclear protein, is potentially involved in the regulation of cell proliferation

Since a negative calcium balance is present in spontaneously hypertensive rats, we searched for the gene(s) involved in this dysregulation. A cDNA library was constructed from the spontaneously hypertensive rat parathyroid gland, which is a key regulator of serum-ionized calcium. From seven overlapping DNA fragments, a 1100-base pair novel cDNA containing an open reading frame of 224 codons was reconstituted. This novel gene, named HCaRG (hypertension-related, calcium-regulated gene), was negatively regulated by extracellular calcium concentration, and its basal mRNA levels were higher in hypertensive animals. The deduced protein showed no transmembrane domain, 67% alpha-helix content, a mutated calcium-binding site (EF-hand motif), four putative "leucine zipper" motifs, and a nuclear receptor-binding domain. At the subcellular level, HCaRG had a nuclear localization. We cloned the human homolog of this gene. Sequence comparison revealed 80% homology between rats and humans at the nucleotide and amino acid sequences. Tissue distribution showed a preponderance in the heart, stomach, jejunum, kidney (tubular fraction), liver, and adrenal gland (mainly in the medulla). HCaRG mRNA was significantly more expressed in adult than in fetal organs, and its levels were decreased in tumors and cancerous cell lines. We observed that after 60-min ischemia followed by reperfusion, HCaRG mRNA declined rapidly in contrast with an increase in c-myc mRNA. Its levels then rose steadily to exceed base line at 48 h of reperfusion. HEK293 cells stably transfected with HCaRG exhibited much lower proliferation, as shown by cell count and [(3)H]thymidine incorporation. Taken together, our results suggest that HCaRG is a nuclear protein potentially involved in the control of cell proliferation.

Studies on flow-mediated vasodilation and intima-media thickness of the brachial artery in patients with primary hyperparathyroidism

The endothelium is a newly recognized target organ of parathyroid hormone (PTH) and may contribute to its effects on vascular tone and blood pressure regulation. Flow-mediated vasodilation (FMD), brachial and carotid intima-media thickness (IMT) were studied in patients with primary hyperparathyroidism (pHPT) and controls to evaluate endothelial function and structural arterial vessel wall alterations. Sixteen patients with pHPT (mean +/- SEM, age 44 +/- 5 years; PTH 229 +/- 72 ng/L; serum calcium 3.0 +/- 0.06 mmol/L; serum phosphate 2.0 +/- 0.2 mg/L) and 16 normocalcemic control subjects matched for age, sex, and blood pressure were included. Diabetes, hypertension, and vascular disease were excluded in both groups. End-diastolic diameter, flow-mediated (FMD) and nitroglycerin-mediated (NMD) dilation of the brachial artery were measured by a multigate pulsed Doppler system (echo-tracking). IMT was determined using automatic analysis of the M-line signal. Endothelium-dependent FMD was impaired in patients compared to controls (4.6 +/- 1.6% v 19.2 +/- 3.9%, P < .001). NMD (23.8 +/- 3.1% v. 22.4 +/- 2.8%, P = NS), carotid and brachial IMT (0.60 +/- 0.04 mm v 0.64 +/- 0.06 mm, P = NS, and 0.46 +/- 0.04 mm v 0.47 +/- 0.08 mm, P = NS, respectively) and artery diameters were not different. Endothelium-dependent vasodilation is impaired in patients with primary hyperparathyroidism despite normal IMT. Endothelial dysfunction may contribute to increased cardiovascular morbidity and mortality in pHPT.

Essential arterial hypertension and stone disease

BACKGROUND

Cross-sectional studies have shown that nephrolithiasis is more frequently found in hypertensive patients than in normotensive subjects, but the pathogenic link between hypertension and stone disease is still not clear.

METHODS

Between 1984 and 1991, we studied the baseline stone risk profile, including supersaturation of lithogenic salts, in 132 patients with stable essential hypertension (diastolic blood pressure of more than 95 mm Hg) without stone disease and 135 normotensive subjects (diastolic blood pressure less than 85 mm Hg) without stone disease who were matched for age and sex (controls). Subsequently, both controls and hypertensives were followed up for at least five years to check on the eventual formation of kidney stones.

RESULTS

Baseline urine levels in hypertensive males were different from that of normotensive males with regards to calcium (263 vs. 199 mg/day), magnesium (100 vs. 85 mg/day), uric acid (707 vs. 586 mg/day), and oxalate (34.8 vs. 26.5 mg/day). Moreover, the urine of hypertensive males was more supersaturated for calcium oxalate (8.9 vs. 6.1) and calcium phosphate (1.39 vs. 0.74). Baseline urine levels in hypertensive females were different from that of normotensive females with regards to calcium (212 vs. 154 mg/day), phosphorus (696 vs. 614 mg/day), and oxalate (26.2 vs. 21.7 mg/day), and the urine of hypertensive females was more supersaturated for calcium oxalate (7.1 vs. 4.8). These urinary alterations were only partially dependent on the greater body mass index in hypertensive patients. During the follow-up, 19 out of 132 hypertensive patients and 4 out of 135 normotensive patients had stone episodes (14.3 vs. 2.9%, chi-square 11.07, P = 0.001; odds ratio 5.5, 95% CI, 1.82 to 16.66). Of the 19 stone-former hypertensive patients, 12 formed calcium calculi, 5 formed uric acid calculi, and 2 formed nondetermined calculi. Of the urinary factors for lithogenous risk, those with the greatest predictive value were supersaturation of calcium oxalate for calcium calculi and uric acid supersaturation for uric acid calculi.

CONCLUSIONS

A significant percentage of hypertensive subjects has a greater risk of renal stone formation, especially when hypertension is associated with excessive body weight. Higher oxaluria and calciuria as well as supersaturation of calcium oxalate and uric acid appear to be the most important factors. Excessive weight and consumption of salt and animal proteins may also play an important role.

Enhanced depressor effect of centrally administered high-calcium solution in salt-loaded experimental hypertension

The depressor effect by oral calcium supplementation is known to be more pronounced in salt-dependent than in renin-dependent hypertension. This study was conducted to investigate the role of central calcium on two different pathophysiologic subtypes of experimental hypertension; (a) salt-dependent, deoxycorticosterone acetate-salt hypertensive rats (DOCA), and (b) renin-dependent, 2-kidney, 1 clip (2-K, 1C) hypertensive rats. In DOCA (n = 10), high-calcium solution (Ca+2, 65.2 mM, 10 microl) given centrally (i.c.v.) elicited a marked decrease in mean blood pressure (MBP; 170 +/- 4 to 138 +/- 5 mm Hg, p < 0.01) with a decrease in heart rate (HR; 390 +/- 18 to 344 +/- 17 beats/min, p < 0.05) lasting for 40 min. In 2-K, 1C (n = 10), high-Ca2+ i.c.v. showed a lesser decrease in MBP (178 +/- 4 to 171 +/- 5 mm Hg) and HR (419 +/- 10 to 395 +/- 12 beats/min) with shorter duration (for 20 min) than in DOCA. This significant depressor and bradycardic response to Ca2+ i.c.v. observed in DOCA was dose dependent at Ca2+ concentrations between 65.2 and 130.4 mM. In DOCA, high Ca2+ i.c.v. reduced the plasma noradrenaline (Nad) concentration significantly (479 +/- 81 to 319 +/- 62 pg/ml, p < 0.05). These results suggest that central Ca2+ plays a more important role in regulating sympathetic nerve activity and BP in salt-dependent than in renin-dependent experimental hypertension.

Secondary hypertension: evaluation and treatment

Most patients with hypertension in the United States have essential (primary) hypertension (95%), the cause of which is unknown. The remaining 5% of adults with hypertension have the secondary form of hypertension, the cause and pathophysiologic process of which are known. Internists and other primary care physicians refer to this as treatable or curable hypertension, because the hypertension can be managed or even controlled with medications. Similarly, the condition is called surgical hypertension by surgeons in the belief that once the cause is determined and identified, surgical intervention will result in cure of hypertension. Secondary causes of hypertension include renal parenchymal disease, renovascular diseases, coarctation of the aorta, Cushing's syndrome, primary hyperaldosteronism, pheochromocytoma, hyperthyroidism, and hyperparathyroidism. Occasionally included in this category are alcohol- and oral contraceptive-induced hypertension and hypothyroidism, but these conditions are not discussed herein. The evaluation of secondary hypertension is of interest and can bring together different facets of anatomy, physiology, pharmacology, and radiology in the medical and surgical treatment of these disorders. Despite enthusiasm that can be generated in the evaluation of these conditions, evaluation can be expensive and should not be conducted for all patients with hypertension. Features that aid in the diagnosis of secondary hypertension include the following: 1. Onset of hypertension before the age of 20 or after the age of 50 years. The presence of hypertension at a young age may suggest coarctation of the aorta, fibromuscular dysplasia, or an endocrine disorder. Hypertension found for the first time after the age of 50 years may suggest the presence of renovascular hypertension caused by atherosclerosis. 2. Markedly elevated blood pressure or hypertension with severe end-organ damage, as in grade III or IV retinopathy. These findings suggest the presence of renovascular hypertension or pheochromocytoma. 3. Specific body habitus and ancillary physical findings. For example, truncal obesity and purple striae occur with hypercortisolism, and exophthalmos is associated with hyperthyroidism. 4. Resistant or refractory hypertension (poor response to medical therapy usually necessitating use of more than three antihypertensive medications from three different classes). 5. Specific biochemical test that suggest the existence of certain disorders, such as hypercalcemia in hyperparathyroidism, hyperglycemia in Cushing's syndrome and pheochromocytoma, and unprovoked hypokalemia with renin-producing tumors, primary hyperaldosteronism, or renin-mediated renovascular hypertension. 6. Other characteristics that may suggest secondary hypertension such as abdominal diastolic bruits (renovascular hypertension), decreased femoral pulses (coarctation of the aorta), or bitemporal hemianopias (Cushing's disease). A combination of a good history and physical examination, astute observation, and accurate interpretation of available data usually are helpful in the diagnosis of a specific causation.

Blood pressure reduction after parathyroidectomy for secondary hyperparathyroidism: further evidence implicating calcium homeostasis in blood pressure regulation

A link between plasma calcium, dietary cations, and blood pressure has been suspected for some time, with human, experimental animal, and epidemiological data adduced to support this hypothesis. We identified 21 patients receiving regular maintenance hemodialysis, but not receiving any regular antihypertensive treatment, who had undergone 22 surgical removals of the parathyroid glands in the period 1978 to 1992. These patients' records were then scrutinized. The group preparathyroidectomy mean systolic blood pressure (BP) was 142.6 +/- 19.4 mm Hg. After the operation, the mean systolic BP was 133.6 +/- 21.9 mm Hg (P = 0.004). Plasma calcium decreased from 2.72 +/- 0.18 mmol/L to 2.52 +/- 0.19 mmol/L (P < 0.001). There was a correlation between the decreases in systolic blood pressure (SBP) (9.4%) and plasma calcium (7.3%); r = 0.60, P = 0.012. The decrease in SBP was not immediate, but delayed some months and complete by approximately 9 months after the operation. Furthermore, using ambulatory BP monitoring in a group of long-term hemodialysis patients, we found that parathyroidectomized patients had lower BP and pulse rates than those with intact parathyroid glands (SBP, 122.9 +/- 16.3 mm Hg v 102.9 +/- 9.9 mm Hg; pulse rates, 87.5 +/- 12.7 v 72.0 +/- 7.5 beats/min, P < .001, nonparathyroidectomy v postparathyroidectomy, both comparisons). These data support a link between plasma calcium and BP in patients receiving maintenance hemodialysis.

The importance of calcium in the control of salt intake

There is no doubt that the renin-angiotensin-aldosterone system (RAAS) can have a major influence on salt intake but the conditions used to demonstrate this are rare outside the laboratory. Changes in RAAS activity do not explain the voluntary intake of NaCl solution shown by non-deprived rats or the preference for salty foods shown by humans. As a first attempt to investigate an alternative mechanism, my colleagues and I are studying the effects of dietary calcium on salt appetite. Even though calcium-deprived rats have normal RAAS activity, they show a striking increase in NaCl intake, which can surpass the effects of the most severe manipulations of the RAAS. The physiological mechanism underlying this behavior is unknown but it probably involves an adrenal factor, perhaps corticosterone. Whatever the mechanism, the calcium-deprived rat and other low-renin models of salt intake provide a promising approach to help understand the physiological basis of excess salt consumption by humans.

Intracellular ionic consequences of dietary salt loading in essential hypertension. Relation to blood pressure and effects of calcium channel blockade

To study the ionic basis of salt sensitivity in hypertension, 19F-, 13P-, and 23Na-nuclear magnetic resonance techniques were used to measure cytosolic free calcium (Cai), pH (pHi), free magnesium (Mgi), and sodium (Nai) in erythrocytes of essential hypertensive subjects (n = 19). Individuals were studied for 2 mo each on low- (UNaV < 50 meq/d) and high- (UNaV > 200 meq/d) salt diets, with the concomitant administration of nifedipine (10 mg t.i.d.) or placebo tablets for 1 mo of each diet. Salt loading elevated Cai and Nai while suppressing Mgi and pHi; these changes occurred predominantly in salt-sensitive subjects (n = 9). Nifedipine blunted the pressor response to salt loading > 50% (delta diastolic BP [high-low salt vs placebo] = 5 +/- 2 vs 14 +/- 2 mmHg, P < 0.05) and reversed salt-induced ionic changes, lowering Cai and elevating Mgi and pHi. Regardless of the definition of salt sensitivity, continuous relationships were observed between the pressure response to salt loading, the levels of Cai (r = 0.726, P < 0.001), Nai (r = 0.747, P < 0.001), and pHi (r = -0.754, P < 0.001), and the salt-induced change in Mgi (r = -0.757, P < 0.001). Altogether, these results emphasize the reciprocal and coordinate nature of intracellular ionic changes in response to dietary salt loading and calcium channel blockade in essential hypertension. They suggest that salt sensitivity is mediated by cellular calcium accumulation from the extracellular space, in association with magnesium depletion and acidification. Lastly, interpretation of intracellular ion measurements in the future will require concurrent assessment of dietary salt intake.

Calcium and sodium handling during volume expansion in essential hypertension

To evaluate the actual role of extracellular fluid volume (ECFV) expansion per se in modulating the rate of urinary calcium excretion, a thermoneutral water immersion (WI) study was conducted in 10 normal subjects and 30 patients with essential hypertension. Central hypervolemia by 2 hours of WI caused a significant diuretic and natriuretic response (P < .005) in normal subjects; no significant changes were detected in urinary calcium and magnesium excretion. WI provoked either an appropriate or exaggerated natriuresis (P < .001) in 21 hypertensive patients; these subjects also exhibited a highly positive correlation between urinary sodium and calcium excretion during WI (P < .001). In the remaining nine hypertensive patients, WI produced a significant diuretic response, but a barely discernible (P = NS) natriuresis (inappropriate response). These subjects also exhibited a significant reduction of urinary calcium (P < .001) and magnesium (P < .01) excretion. The data indicate that (1) volume expansion per se may have a role in regulating calcium excretion in hypertensive subjects; (2) a calcium leak may be attributable to a close relationship between urinary sodium and calcium metabolism, and causally related to a disturbance of sodium and volume homeostasis in hypertension.

Renal Ca2+ + Mg2+ ATPase in congestive heart failure due to diabetes

The authors have previously shown that atrial natriuretic peptide (ANP) mediates its cellular effects in part by changes in Ca2+ homeostasis in kidney cortex and that Ca2+ + Mg2+ ATPase is linked to ANP receptors, being reciprocally modulated by the guanylate cyclase system. The present study was designed to examine the status of this coupling in diabetes-induced congestive heart failure and the effect of its alterations on the functional integrity of the renal cell. Ca2+ + Mg2+ ATPase and guanylate cyclase were tested in hypertensive-diabetic rats (D + H), which develop congestive heart failure (CHF) at ten weeks following streptozotocin (65 mg/kg) injection and abdominal aortic constriction. The ATPase activity was measured by the release of 32P from [gamma-32P]ATP in the medium. While the guanylate cyclase activity was decreased very rapidly in the hypertensive-diabetic group, the sensitivity of the Ca2+ pump to ANP was increased at an early stage (three weeks) and decreased at a late stage (ten weeks) of CHF. The authors conclude that a defect in coupling between the Ca2+ pump and the ANP-receptor system as observed in the D + H group may contribute to the development of nephropathy and CHF.

High-calcium diet in spontaneously hypertensive rats: intervention with calcium antagonist verapamil

A number of studies have shown an antihypertensive effect for high-calcium diets, but others have found no effect or, even a prohypertensive effect. Because of these disparate results, studies were conducted in spontaneously hypertensive rats (SHR) fed either a normal calcium diet (1.0% calcium) or a high-calcium diet (4.0% calcium) with or without verapamil HCl (50 mg/kg body weight) from ages 5 to 12 weeks. Systolic blood pressure (SBP) and heart rate (HR) were measured by indirect tail cuff method. During the analysis of the electrolytes and vasoactive hormones monitored in this study, it was found that rats fed high-calcium diet had significantly elevated serum ionized and total calcium and calcium excretion. Systolic blood pressure for the verapamil-normal calcium diet (week 5, 148 +/- 4 mm Hg; week 7, 162 +/- 4 mm Hg) did not differ significantly from that of normal calcium diet (week 5, 152 +/- 2 mm Hg; week 7, 160 +/- 1 mm Hg). The high-calcium diet potentiated the development of hypertension, i.e., SBP was (157 +/- 2 mm Hg) on the 5th week and (174 +/- 4 mm Hg) on the 7th week. Conversely, verapamil high-calcium diet prevented the development of hypertension (week 5, SBP was 139 +/- 4 mm Hg; week 7, SBP was 146 +/- 3 mm Hg).(ABSTRACT TRUNCATED AT 250 WORDS)

The hemodynamic effect of dietary calcium supplementation on rat renovascular hypertension

Mechanisms which could be responsible for the hypotensive effects of increasing calcium intake from 1.2 to 2.5% of diet were examined in two kidney, one clip renovascular hypertension (2K, 1C RHV) in male Sprague-Dawley rats. Plasma renin activity was elevated similarly in NCA and HCA rats. No evidence for volume or phosphate depletion was found in HCA animals. Cardiac output was not different. Decreased sensitivity was demonstrated to moderate doses of norepinephrine in HCA rats, while vascular reactivity to exogenously administered angiotensin II over the range of doses used was not different between diets. The antihypertensive effect of supplemental calcium was associated with a 39% reduction in systemic vascular resistance. Therefore, dietary calcium supplementation lowers blood pressure in 2-K, 1C RVH primarily due to a systemic vasodilatation and reduced vascular reactivity to moderate doses of norepinephrine.

Lewis K. Dahl Memorial Lecture. The renin system and four lines fo hypertension research. Nephron heterogeneity, the calcium connection, the prorenin vasodilator limb, and plasma renin and heart attack

As the major regulator of arterial blood pressure and sodium balance, the renin axis supports normotension or hypertension via angiotensin-mediated vasoconstriction and angiotensin plus aldosterone-induced renal sodium retention. In this endocrine servo control, renal renin is released by hypotension or salt depletion; conversely, with hypertension or volume excess, plasma renin activity falls to zero. Accordingly, any renal renin secretion is abnormal in the face of arterial hypertension. Human hypertensive disorders comprise a spectrum of abnormal vasoconstriction-volume products (renin-sodium profiles). Excess plasma renin activity for the sodium balance is created by nephron heterogeneity in which a subpopulation of ischemic nephrons hypersecretes renin and retains sodium. This excess renin impairs adaptive natriuresis of neighboring normal nephrons. Research defining the pivotal role of vascular cytosolic calcium for transducing sodium or renin-mediated vasoconstriction explains the selective value of calcium antagonists for correcting the sodium-volume-mediated, and beta-blockers or angiotensin converting enzyme inhibitors for correcting renin-mediated, arteriolar vasoconstriction. The renin precursor prorenin appears to be physiologically active, causing selective vasodilation that offsets renin-mediated vasoconstriction. Overactivity of prorenin may be involved in the hyperperfusion vascular injuries of diabetes mellitus and toxemias. Prorenin underactivity may facilitate renin-mediated ischemic vascular injury. In essential hypertension, undue plasma renin activity is powerfully and independently associated with heart attack risk. Conversely, patients with low renin activity are protected from heart attack despite higher blood pressures and greater age. Also, renin or angiotensin administration consistently causes vascular injury in the heart, brain, and kidneys of animals. These data suggest new potentials for the prevention of cardiovascular sequelae (heart attack and stroke) by using explicit strategies to curtail plasma renin activity.

Cellular calcium and magnesium metabolism in the pathophysiology and treatment of hypertension and related metabolic disorders

We have investigated the cellular basis for the clinical and epidemiologic linkage of hypertension, left ventricular hypertrophy (LVH), obesity, and non-insulin-dependent diabetes mellitus (NIDDM) and have studied cytosolic free calcium and free magnesium levels in these syndromes. Specifically, intracellular free calcium is elevated and free magnesium is deficient in hypertension, and both are related (directly and inversely, respectively) to the ambient level of blood pressure, to LV mass index (and thus to the degree of cardiac hypertrophy), and to the hyperinsulinemia and insulin resistance of essential hypertension. Dynamically, the ability of dietary salt loading to elevate blood pressure corresponds to its ability to elevate cytosolic free calcium and reciprocally to suppress free magnesium levels. Conversely, the ability of calcium channel blockade to reverse salt-induced hypertension is related to its ability to prevent these transmembrane ionic effects. Higher steady-state free calcium or lower free magnesium, or both, are also observed in clinical states linked to hypertension, such as obesity and NIDDM. Oral glucose loading in normal subjects itself elevates free calcium and suppresses free magnesium levels, as does hyperglycemia in vitro. These data suggest an ionic hypothesis of cardiovascular and metabolic disease, in which a generalized defect in cell ion handling is present in all tissues, resulting in higher steady-state free calcium and lower free magnesium levels. In pancreatic beta cells, this would produce hyperinsulinemia; in fat and skeletal muscle, cause peripheral insulin resistance; and in renal tissue, increase proximal sodium resorption and increase urinary calcium excretion--all features of essential hypertension. In vascular smooth muscle, high cytosolic free calcium would increase smooth muscle tone and cause vasoconstriction, and in heart muscle, independent of blood pressure, would increase contractility and predispose to LVH. Therefore, what may appear clinically to be the separate syndromes of hypertension, obesity, and NIDDM may pathophysiologically be different manifestations of the same underlying cellular defect, thus explaining their frequent clinical coexistence. Therapeutically, reversal of this excess free calcium accumulation and/or free magnesium deficit with ion-specific agents, such as calcium channel blocking drugs, may thus ameliorate not only the elevated blood pressure of hypertension but also the concurrent excess morbidity and mortality of the concurrent cardiac, vascular, and metabolic aspects of the hypertensive state.

Glucose tolerance and insulin action in rats with renovascular hypertension

To test whether hypertension can cause hyperinsulinemia or insulin resistance, we performed intravenous glucose tolerance tests at 1 month and euglycemic clamps at 3 months after induction of two-kidney, one clip renovascular hypertension in rats. At 1 month, systolic pressure was higher in 21 clipped than in 12 control animals (161 +/- 5 mm Hg, range 134-187 mm Hg versus 119 +/- 3 mm Hg, range 108-146 mm Hg; p less than 0.001). Glucose tolerance, assessed as the glucose fractional disappearance rate between 3 and 11 minutes after the glucose injection, was similar in the clipped and sham groups (0.059 +/- 0.002 versus 0.056 +/- 0.002 min-1, respectively; p greater than 0.4). The total area under the insulin curve during glucose tolerance tests was also similar in the clipped and sham groups (926 +/- 95 versus 869 +/- 126 microunits/ml x min; p greater than 0.4). There was no significant relation between systolic blood pressure and insulin area during glucose tolerance tests in the clipped group, but there was a positive rectilinear relation in the control group (r = 0.66; p = 0.01). Fourteen animals had euglycemic clamps 2 months after glucose tolerance tests. At that time, systolic pressure (direct femoral measurement) was higher in the seven clipped animals (189 +/- 13 mm Hg versus 122 +/- 5 mm Hg in controls; p less than 0.001). Insulin infusions of 1 and 4 milliunits/min/kg body wt effected similar plasma insulin levels in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of hypertension. Useful nonpharmacologic measures

Hypertension is a chronic problem commonly seen by primary care physicians. Inadequate treatment may result in significant morbidity and even death. Therefore, all patients with hypertension or at risk for hypertension should be educated about nonpharmacologic measures to control blood pressure. Weight reduction and sodium restriction are cornerstones of nonpharmacologic management of hypertension. Although studies of the effects of aerobic exercise on blood pressure are not well designed, data confirm the value of such exercise. Relaxation therapy has been shown to lower blood pressure, but effects may be transient. Potassium and calcium supplementation has lowered blood pressure, but because study results are contradictory, the exact clinical criteria for use of such supplements have not been determined. Vegetarians have lower blood pressure than nonvegetarians, but no specific dietary components (eg, fiber, fat) have been documented as the beneficial factors. Because of its significant pressor effect, alcohol should be avoided by hypertensives. A low-fat diet is recommended to decrease cardiovascular risk and assist in weight control.

The crucial role of physiological Ca2+ concentrations in the production of endothelial nitric oxide and the control of vascular tone

1. The effect of varying the extracellular Ca2+ concentration on the basal and acetylcholine (ACh)-induced release of nitric oxide (NO) from the rabbit aorta was investigated by use of a superfusion bioassay system. 2. Changes between 0.5 and 2.0 mM in the concentration of Ca2+ superfusing the detector bioassay tissues or perfusing endothelium-denuded donor aortae had no effect on the tone of these tissues. 3. Increasing the concentration of Ca2+ perfusing endothelium-containing donor aortae from zero to 1.25 mM caused a transient (24 +/- 9 min), concentration-dependent basal release of NO, which was attenuated at higher concentrations of Ca2+ (1.5-2.0 mM). 4. The duration of the effect of Ca2+ on the basal release of NO was increased by a concomitant infusion of L-arginine (100 microM) through the donor aorta. 5. Changes in the concentration of Ca2+ between 0.5 and 2.0 mM had a similar biphasic effect on the release of NO induced by ACh, which was also maximal at 1.25 mM Ca2+. 6. When Ca2+ was removed from the Krebs buffer perfusing the donor aorta, the basal release of NO declined within 2 min. In contrast, the release of NO induced by ACh declined progressively over 60 min. 7. Thus changes in the concentration of Ca2+ around the physiological range modulate the synthesis of NO by the vascular endothelium and consequently, vascular tone. This may account for the effects of dietary Ca2+ supplements on the control of some hypertensive states.

The effect of diets adequate and deficient in calcium on blood pressures and the activities of intestinal and kidney plasma membrane enzymes in normotensive and spontaneously hypertensive rats

Basolateral and brush-border membranes were prepared from the intestines and kidneys of spontaneously hypertensive (SHR) and normotensive (WKY) rats fed on a calcium-adequate diet and assayed for their enzyme activities. In intestinal basolateral membranes the activities of Na+ K(+)-ATPase (EC 3.6.1.37) Ca2(+)-ATPase (EC 3.6.1.38) and alkaline phosphatase (EC 3.1.3.1) were lower in SHR rats when compared with WKY rats, whilst 5'-nucleotidase (EC 3.1.3.5) (a marker for basolateral membranes) was unaffected. In kidney basolateral membranes all enzymes were similar in activity in SHR and WKY rats. In intestinal brush-border membranes the activities of Ca2(+)-ATPase and alkaline phosphatase were lower in SHR rats when compared with WKY rats, whilst microvillus aminopeptidase (EC 3.4.11.2) (a marker for brush-border membranes) was unaffected. In kidney brush-border membranes all enzymes were similar in activity in SHR and WKY rats. The blood pressures of the SHR rats were considerably higher than those of the WKY rats. When SHR rats were fed on a Ca-deficient diet the activities of Na+K(+)-ATPase, Ca2(+)-ATPase and alkaline phosphatase in basolateral membranes and Ca2(+)-ATPase and alkaline phosphatase in brush-border membranes were all increased in the intestine when compared with SHR rats fed on a Ca-adequate diet. The equivalent enzymes in the kidneys of SHR rats, and the intestines and kidneys of WKY rats, were not affected by altering the Ca in the diet. The blood pressures of SHR rats fed on a Ca-deficient diet were higher than in those fed on a Ca-adequate diet. Blood pressures of WKY rats were not affected by altering the diet in this way. The results indicate that the absorption of Ca by active mechanisms may be reduced in SHR rats compared with WKY rats. Changing the level of Ca in the diet modified both blood pressure and the activities of enzymes which catalyse active Ca transport. The implications of these results to the aetiology, and possible nutritional treatment, of essential hypertension are discussed.

Hypertension and abnormal glucose homeostasis. Possible role of divalent ion metabolism

Recent epidemiologic and clinical evidence emphasizes the association of hypertension, peripheral insulin resistance, hyperinsulinemia, and/or frank diabetes mellitus. The underlying basis for this clinical association remains unknown, and much attention has been focused on a possible role for hyperinsulinemia in these processes. However, evidence also suggests direct hypotensive effects of insulin. It is therefore unclear to what extent hyperinsulinemia contributes to, rather than merely reflects, these multiple metabolic abnormalities. Recent research links both hypertension and diabetes to common defects in calcium and magnesium metabolism, at least in part described by increased cytosolic free calcium, suppressed intracellular free magnesium, and their associated intracellular and hormonal alterations. Thus, hypertension, peripheral insulin resistance, and hyperinsulinemia may be different clinical manifestations of a common underlying cellular defect in divalent ion metabolism.

A prospective study of nutritional factors and hypertension among US women

The relation of various nutritional factors with hypertension was examined prospectively among 58,218 predominantly white US female registered nurses, aged 34-59 years. In 1980, all women completed an independently validated dietary questionnaire. During 4 years of follow-up, 3,275 women reported a diagnosis of hypertension; the validity of the self-report was shown in a subsample. Age, relative weight, and alcohol consumption were the strongest predictors for the development of hypertension. Dietary calcium and magnesium had independent and significant inverse associations with hypertension. For women with a calcium intake of at least 800 mg/day, the relative risk of hypertension was 0.78 (95% confidence interval, 0.69-0.88) when compared with an intake of less than 400 mg/day. The relative risk for magnesium intake of 300 mg/day or more compared with an intake of less than 200 mg/day was 0.77 (95% confidence interval, 0.67-0.88). For women with high intakes of both calcium and magnesium compared with those having low intakes of both, the relative risk of hypertension was 0.65 (95% confidence interval, 0.53-0.80). No independent associations with hypertension were observed for intakes of potassium, fiber, and saturated and polyunsaturated fatty acids. These prospective findings add to the growing evidence to support the need for randomized trials to determine whether there is a protective role of dietary calcium and magnesium in the regulation of blood pressure.

Aggravation of salt-induced hypertension in Dahl rats by 2% supplemental dietary calcium

There is considerable interest in the antihypertensive potential of supplemental dietary calcium in salt-sensitive hypertension. Previously we reported that very high dietary calcium (4.0% vs. 0.4%) lowers mean arterial pressure in Dahl salt-sensitive (DS) hypertensive rats. However, we have recently observed that more moderate calcium supplementation (2.0% vs. 0.4%) increases mean arterial pressure in DS rats. To further evaluate the pressor action of 2.0% versus 0.4% calcium, we tested for effects of 2.0% calcium in female DS rats fed low (0.2%), moderate (1.0%), and high (2.7%) sodium and in Dahl salt-resistant (DR) rats fed high sodium from 6 to 12 weeks old (n = 10-13 rats per group). At 12 weeks, 2.0% calcium increased mean arterial pressure and the cardiac ventricular weight/body weight ratio in DS rats fed high sodium (p less than 0.05) but not in DS rats fed low or moderate sodium or in DR rats fed high sodium. Ganglionic blockade decreased mean arterial pressure in all groups but failed to abolish or attenuate the difference in mean arterial pressure between high sodium-fed DS rats on 2.0% and 0.4% calcium diets. In the same DS rats fed a high sodium diet, 2.0% calcium increased systemic pressor responsiveness to graded norepinephrine administration after ganglionic blockade. Thus, 2.0% supplemental calcium intake enhances salt-induced hypertension in DS rats. This prohypertensive action of 2.0% calcium is dependent on a critically high level of between 1.0% and 2.7% sodium in the diet.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular consequences of magnesium deficiency and loss: pathogenesis, prevalence and manifestations--magnesium and chloride loss in refractory potassium repletion

Dietary magnesium (Mg) deficiency is more prevalent than generally suspected and can cause cardiovascular lesions leading to disease at all stages of life. The average American diet is deficient in Mg, especially in the young, in alcoholic persons, and in those under stress or with diseases or receiving certain drug therapies, who have increased Mg needs. Otherwise normal, Mg-deficient diets cause arterial and myocardial lesions in all animals studied, and diets that are atherogenic, thrombogenic and cardiovasopathic, as well as Mg-deficient, intensify the cardiovascular lesions, whereas Mg supplementation prevents them. Diuretics and digitalis can intensify an underlying Mg deficiency, leading to cardiac arrhythmias that are refractory unless Mg is added to the regimen. Potassium (K) depletion in diuretic-treated hypertensive patients has been linked to an increased incidence of ventricular ectopy and sudden death. K supplementation alone is not the answer. Mg has been found to be necessary to intracellular K repletion in these patients. Because patients with congestive heart failure and others receiving diuretic therapy are also prone to chloride loss leading to metabolic alkalosis that also interferes with K repletion, the addition of Mg and chloride supplements in addition to the K seems prudent.

Effect of oral calcium on blood pressure response in salt-loaded borderline hypertensive patients

To clarify the mechanism of the antihypertensive effect of oral calcium loading, we studied the effect of low versus high calcium intake on salt-induced blood pressure elevations in patients with borderline hypertension. After a 7-day period of dietary salt restriction (50 meq/day), 27 patients were placed on a high salt (300 meq/day), low calcium (250 mg/day) diet for 7 days; 14 of these patients were given 2,160 mg/day of supplementary calcium (Ca group), and 13 patients were given placebo (non-Ca group). With a high salt intake, the percent increase in mean blood pressure was smaller in the Ca group than in the non-Ca group (+2.85 +/- 1.22% vs. +8.63 +/- 1.66%, respectively, p less than 0.01). The Ca group showed a smaller weight gain (p less than 0.05) and a greater urinary excretion of sodium (p less than 0.005) than the non-Ca group. In the Ca group, but not in the non-Ca group, high salt intake resulted in an increase in intraerythrocyte magnesium content (p less than 0.01), which was correlated inversely with the salt-induced changes in mean blood pressure (r = -0.54, p less than 0.05). While the increase in cellular magnesium was greater in the Ca group, the changes in red blood cell sodium and sodium/potassium ratio were not different between the two groups. The results suggest that oral calcium supplementation may prevent a rise in blood pressure in patients on a high salt, low calcium diet by attenuating the sodium retention.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship of serum sodium, potassium, calcium, and phosphorus with blood pressure. Belgian Interuniversity Research on Nutrition and Health

During an epidemiological survey on the relationship between diet and cardiovascular risk factors, serum sodium, potassium, calcium, phosphorus, and total protein were measured in 4167 men and 3891 women with a mean age of 49 years. Several consistent and highly significant correlations were found between serum cation and phosphorus levels and blood pressure. The analysis was performed separately in the total group and in the group not receiving treatment for hypertension. A highly significant negative correlation existed between serum sodium and both systolic and diastolic blood pressure. Serum potassium correlated negatively with blood pressure only in men. Serum phosphorus correlated negatively in men and women with systolic blood pressure. Serum calcium correlated positively with systolic and diastolic blood pressure in men, but only with diastolic blood pressure in women. All these correlations were independent of serum total protein. A significant negative correlation between serum phosphorus and heart rate and a significant positive correlation between the serum calcium/phosphorus ratio and heart rate were demonstrated.

Effects of calcium antagonists on deranged modulation of the renal function curve in salt-sensitive patients with essential hypertension

Two subsets of patients with essential hypertension have been identified based on their sensitivity to dietary sodium intake: the salt-sensitive and the salt-resistant patients. The renal function curve in salt-resistant patients is shifted to higher blood pressure levels but it remains parallel to that of normal subjects. On the contrary, the slope of the renal function curve in salt-sensitive patients is considerably depressed. It is postulated that this derangement may be related to an abnormal relation between sodium intake and sympathetic nervous system activity. It is also postulated that a link exists between abnormalities of sodium and calcium metabolism in hypertension and that reduced renin release, increased sympathetic activity and reduced renal sodium excretion in salt-sensitive patients may be related to a defect in sodium-linked cellular calcium transport. Calcium antagonists revert the derangements in the renal function curve and in renin release in salt-sensitive patients.

Calcium metabolism, calcium-channel blocking agents, and hypertension management

Increasing evidence has suggested that a disturbance of cellular calcium metabolism may have a role in initiating and maintaining elevated systemic vascular resistance in essential hypertension. Controversy exists over whether calcium can alleviate or exacerbate the hypertensive process, and diversity of calcium metabolism in hypertensive patients has been proposed. Calcium-channel blocking agents are potent vasodilators capable of correcting the elevated systemic vascular resistance. Clinical studies have shown that these drugs have antihypertensive efficacy comparable to established agents. The elderly, blacks, and patients with low renin activity respond well to calcium-channel blockers. These drugs may also offer potential advantages over established antihypertensive agents in patients with other coexisting diseases. Sustained release formulations have been developed, and initial experience with long-term efficacy and tolerability is encouraging. The calcium-channel blockers may become first-line therapy for treatment of hypertension in selected patients.

Salt sensitivity and systemic hypertension in the elderly

Aging in industrialized societies is accompanied by increases in the incidence and prevalence of hypertension, with a disproportionately greater increase occurring among aging blacks than among aging whites. This geriatric hypertension is generally of a salt-sensitive nature with a disproportionate frequency of isolated systolic hypertension. Although salt-taste acuity declines with age, salt sensitivity among the elderly does not appear to result from a compensatory increase in salt intake. Rather, age-related increases in salt sensitivity result, in part, from a reduced ability to appropriately excrete a salt load, which is due to a decline in renal function and to a reduced generation of natriuretic substances such as prostaglandin E2 and dopamine. Age-associated declines in the activity of membrane sodium/potassium-adenosine triphosphatase (Na/K-ATPase) may also contribute to geriatric hypertension because this results in increased intracellular sodium that may cause reduced sodium-calcium exchange and thereby increase intracellular calcium and vascular resistance. Reductions in cellular calcium efflux due to reduced calcium-ATPase activity may similarly cause an increase in intracellular calcium and vascular resistance. Increasing dietary calcium intake may represent an effective nonpharmacologic treatment for some salt-sensitive persons because it appears to reduce intracellular calcium by (1) suppressing parathyroid hormone-mediated calcium influx, (2) increasing Na/K-ATPase activity, and (3) reducing intravascular volume due to calcium-induced natriuresis.

Two forms of vasoconstriction in systemic hypertension

Clinical, pharmacologic and biochemical evidence characterizes essential hypertension as a heterogeneous spectrum of pathophysiologic substances rather than the single entity it has long been presumed to be. Although the causes of essential hypertension remain obscure, 2 different mechanisms for long-term vasoconstriction that sustain diastolic hypertension in the experimental and clinical forms of primary aldosteronism and renovascular hypertension can also be identified and quantified among patients with essential hypertension. The first mechanism is renin independent, requires antecedent sodium retention and appears related to abnormal membrane transport of calcium. This vasoconstriction is identified by low plasma renin and ionized calcium and is correctable by sodium depletion or calcium channel or alpha blockade. The second vasoconstrictor mechanism is renin mediated and involves an increase in cytosolic calcium. This mechanism is quantifiable by the plasma renin level or the hypotensive response to an antirenin-system drug (converting enzyme inhibitor, beta blocker or saralasin). Depending on the state of sodium balance, these 2 mechanisms contribute reciprocally to maintenance of arteriolar tone in experimental models, in both normal and hypertensive people, and in patients with congestive heart failure. In these situations, at the extremes of the range of plasma renin values, one or the other mechanism predominates, whereas in the medium range of renin values both mechanisms can be operative. These interrelations provide a basis for applying more precisely tailored therapy and for stratifying patients pathophysiologically for further study.

Calcium, the renin-aldosterone system, and the hypotensive response to nifedipine

Ionic, hormonal, and blood pressure responses to a single oral dose of the calcium channel blocker nifedipine were assessed in 25 essential hypertensive subjects. When grouped according to their renin-sodium profile, low renin subjects had a greater hypotensive response to nifedipine (change in diastolic blood pressure -20.0 +/- 1.4 vs -6.4 +/- 1.0%; p less than 0.005) than did high renin hypertensive subjects. The initial level of serum ionized calcium predicted the blood pressure response to nifedipine (r = 0.70, p less than 0.001), as did the initial plasma renin activity (r = 0.65, p less than 0.005). Nifedipine induced a transient rise in serum ionized calcium (from 2.22 +/- 0.02 to 2.28 +/- 0.02 mEq/L; p less than 0.01), while plasma renin activity was consistently elevated compared with initial values at 30 (p less than 0.01), 60 (p less than 0.01), and 120 (p less than 0.05) minutes after drug administration. By comparison, plasma aldosterone levels did not rise and even declined at 30 (p less than 0.01), 60 (p less than 0.05), and 120 (p less than 0.05) minutes after nifedipine. These results suggest that low renin hypertension is more critically dependent on extracellular calcium than are higher renin forms and demonstrate that levels of serum ionized calcium, plasma renin activity, or both may predict the sensitivity of blood pressure to calcium channel blockade. Lastly, calcium may play a pivotal role in vivo in coupling renin stimulation to adrenal aldosterone responses.