Uremia increases gastric mucosal permeability and acid back-diffusion injury in the rat

Severe Anemia from Multiple Gastric Hyperplastic Polyps in a Hemodialysis Patient after Long-term Use of a Proton-pump Inhibitor

A 90-year-old man on maintenance hemodialysis was admitted due to severe symptomatic anemia. Biopsies under esophagogastroduodenoscopy demonstrated that the cause of anemia was intermittent blood oozing from multiple gastric hyperplastic polyps. Even after successful eradication of Helicobacter pylori, he showed hypergastrinemia (480 pg/mL) owing to esomeprazole (proton-pump inhibitor) therapy for the past 4.5 years to treat reflux esophagitis. Seven months after we switched esomeprazole to famotidine (H2-receptor antagonist), those gastric polyps and anemia were remarkably ameliorated with lowered gastrin levels. This case indicates that long-term use of a proton-pump inhibitor triggers chronic hypergastrinemia, leading to gastric hyperplastic polyps and subsequent severe anemia.

Fecal microbiota analysis of polycystic kidney disease patients according to renal function: A pilot study

IMPACT STATEMENT

The heterogeneity of the renal disease, therapeutic interventions, and the original cause of the renal failure, all directly affect the microbiota. We delineate in this report the direct effect of decreased renal function on the bacterial composition following stringent criteria to eliminate the possibilities of other confounding factors and dissect the direct effects of the uremic milieu. We analyzed the microbiome following three different approaches to further evaluate the effects of mild, moderate and advanced renal insufficiency on the microbiome. We also present here a detailed functional analysis of the projected altered pathways secondary to changes in the microbiome composition.

Chronic kidney disease, uremic milieu, and its effects on gut bacterial microbiota dysbiosis

Several lines of evidence suggest that gut bacterial microbiota is altered in patients with chronic kidney disease (CKD), though the mechanism of which this dysbiosis takes place is not well understood. Recent studies delineated changes in gut microbiota in both CKD patients and experimental animal models using microarray chips. We present 16S ribosomal RNA gene sequencing of both stool pellets and small bowel contents of C57BL/6J mice that underwent a remnant kidney model and establish that changes in microbiota take place in the early gastrointestinal tract. Increased intestinal urea concentration has been hypothesized as a leading contributor to dysbiotic changes in CKD. We show that urea transporters (UT)-A and UT-B mRNA are both expressed throughout the whole gastrointestinal tract. The noted increase in intestinal urea concentration appears to be independent of UTs' expression. Urea supplementation in drinking water resulted in alteration in bacterial gut microbiota that is quite different than that seen in CKD. This indicates that increased intestinal urea concentration might not fully explain the CKD- associated dysbiosis.

Gastric Hypersecretory States: Investigation and Management

OPINION STATEMENT

Hypersecretory conditions affecting the stomach account for significant morbidity and mortality manifested in some cases with peptic ulcer, gastrointestinal hemorrhage, and/or gastroesophageal reflux disease (GERD). The diagnosis of gastric acid hypersecretory states can be challenging and relies on the use of quantitative assays to measure gastric acid secretion and serum gastrin. The most common etiology for hypergastrinemia is the use of potent gastric acid inhibitors such as the proton pump inhibitors. The differential diagnosis of this condition is of critical importance, and will dictate management decisions. Conditions such as atrophic gastritis are relatively benign and can lead to hypergastrinemia without the presence of gastric acid hypersecretion. Zollinger-Ellison syndrome, on the other hand, causes hypergastrinemia with profound gastric acid hypersecretion [1]. More common causes of hypergastrinemia include gastric outlet obstruction, ileus, and chronic renal failure [2]. In most cases, proton pump inhibitors will be used to manage these conditions. In some instances, surgical therapy may be required. This chapter will review the important clinical causes of gastric acid hypersecretion and provide insights to the best medical management options to better care for patients with these disorders.

Helicobacter pylori status and esophagogastroduodenal mucosal lesions in patients with end-stage renal failure on maintenance hemodialysis

OBJECTIVES

The aim of this study was to elucidate the impact of Helicobacter pylori infection on esophagogastroduodenal mucosal lesions in patients with end-stage renal failure on maintenance hemodialysis (HD).

METHODS

An upper endoscopy and the (13)C-urea breath test were performed in 198 patients on maintenance HD. Clinical features, serum pepsinogen levels and esophagogastroduodenal mucosal lesions were compared between H. pylori-positive and H. pylori-negative patients. Risk factors associated with esophagogastroduodenal mucosal lesion were determined by multivariate analyses.

RESULTS

The upper endoscopy revealed that gastric erosion was the most frequent (58%) type of esophagogastroduodenal mucosal lesion, followed by duodenal erosion (18%), gastric ulcer (14%), gastroesophageal reflux disease (10%), and duodenal ulcer (7%). Of the 198 patients enrolled in the study, 81 were positive and 117 patients were negative for H. pylori infection. The time duration after the introduction of HD was significantly longer and serum pepsinogen I/II ratio was significantly higher in H. pylori-negative patients than in H. pylori-positive patients. Multivariate analyses revealed that the H. pylori infection was an independent, protective factor for gastric erosion (odds ratio 0.38; 95% confidence interval 0.21-0.70), while the infection was unrelated to other mucosal lesions.

CONCLUSIONS

The most common mucosal lesion observed in our study cohort, all of whom were patients on maintenance HD, was gastric erosion. The high prevalence of this type of lesion may be explained partly by the cure of H. pylori infection during the clinical course of maintenance HD.

Acute adaptive cellular base uptake in rat duodenal epithelium

We studied the role of duodenal cellular ion transport in epithelial defense mechanisms in response to rapid shifts of luminal pH. We used in vivo microscopy to measure duodenal epithelial cell intracellular pH (pH(i)), mucus gel thickness, blood flow, and HCO secretion in anesthetized rats with or without the Na(+)/H(+) exchange inhibitor 5-(N,N-dimethyl)-amiloride (DMA) or the anion transport inhibitor DIDS. During acid perfusion pH(i) decreased, whereas mucus gel thickness and blood flow increased, with pH(i) increasing to over baseline (overshoot) and blood flow and gel thickness returning to basal levels during subsequent neutral solution perfusion. During a second brief acid challenge, pH(i) decrease was lessened (adaptation). These are best explained by augmented cellular HCO uptake in response to perfused acid. DIDS, but not DMA, abolished the overshoot and pH(i) adaptation and decreased acid-enhanced HCO secretion. In perfused duodenum, effluent total CO(2) output was not increased by acid perfusion, despite a massive increase of titratable alkalinity, consistent with substantial acid back diffusion and modest CO(2) back diffusion during acid perfusions. Rapid shifts of luminal pH increased duodenal epithelial buffering power, which protected the cells from perfused acid, presumably by activation of Na(+)-HCO cotransport. This adaptation may be a novel, important, and early duodenal protective mechanism against rapid physiological shifts of luminal acidity.

Decreased endothelial nitric oxide synthase in gastric mucosa of rats with chronic renal failure

According to recent reports, chronic renal failure (CRF) increases the susceptibility of gastric mucosa to injury. Since nitric oxide plays a major role in gastric mucosal defense and injury, we investigated, in rats with CRF produced by five-sixths nephrectomy and in control rats, the expression of nitric oxide synthase(NOS) in the stomach and measured mucosal and submucosal gastric blood flow. In CRF rats, gastric mucosal blood flow was significantly reduced compared with control rats, whereas submucosal and serosal blood flow was significantly increased. CRF significantly decreased endothelial NOS (eNOS) mRNA abundance by 53% (P < 0.01) and reduced expression of eNOS protein by 42% (P < 0.01) compared with the controls. Enzyme activity of eNOS was significantly reduced in gastric mucosa of CRF rats (P < 0.05). These data are consistent with reduced gastric mucosal blood flow in CRF rats and can explain altered susceptibility of gastric mucosa to injury in CRF rats.

Neural emergency system in the stomach

The maintenance of gastric mucosal integrity depends on the rapid alarm of protective mechanisms in the face of pending injury. Afferent neurons of extrinsic origin constitute an emergency system that is called into operation when the gastric mucosa is endangered by acid and other noxious chemicals. The function of these chemoceptive afferents can be manipulated selectively and explored with the excitotoxin capsaicin. Most of the homeostatic actions of capsaicin-sensitive afferents are brought about by peptides released from their peripheral endings in the gastric wall. When stimulated, chemoceptive afferents enhance gastric blood flow and activate hyperemia-dependent and hyperemia-independent mechanisms of protection and repair. In the rodent stomach, these local regulatory roles of sensory neurons are mediated by calcitonin gene-related peptide acting via calcitonin gene-related peptide 1 receptors and neurokinin A acting via neurokinin 2 receptors, with both peptides using nitric oxide as their common messenger. In addition, capsaicin-sensitive neurons form the afferent arc of autonomic reflexes that control secretory and motor functions of the stomach. The pathophysiological potential of the neural emergency system is best portrayed by the gastric hyperemic response to acid backdiffusion, which is signaled by afferent nerve fibers. This mechanism limits damage to the surface of the mucosa and creates favorable conditions for rapid restitution and healing of the wounded mucosa.

Tachykinin inhibition of acid-induced gastric hyperaemia in the rat

1. Primary afferent neurones releasing the vasodilator, calcitonin gene-related peptide, mediate the gastric hyperaemic response to acid back-diffusion. The tachykinins neurokinin A (NKA) and substance P (SP) are located in the same neurones and are co-released with calcitonin gene-related peptide. In this study we investigated the effect and possible role of tachykinins in the acid-evoked gastric vasodilatation in urethane-anaesthetized rats. 2. Gastric acid back-diffusion, induced by perfusing the stomach with 15% ethanol in the presence of 0.05 M HCl, increased gastric mucosal blood flow by 60-90%, as determined by the hydrogen clearance technique. NKA and SP (0.14-3.78 nmol min-1 kg-1, infused intra-aortically) inhibited the gastric mucosal hyperaemic response to acid back-diffusion in a dose-dependent manner, an effect that was accompanied by aggravation of ethanol/acid-induced macroscopic haemorrhagic lesions. 3. The inhibitory effect of NKA (1.26 nmol min-1 kg-1) on the acid-induced gastric mucosal vasodilatation was prevented by the tachykinin NK2 receptor antagonists, MEN 10,627 (200 nmol kg-1) but left unaltered by the NK1 receptor antagonist, SR 140,333 (300 nmol kg-1) and the mast-cell stabilizer, ketotifen (4.6 mumol kg-1). 4. Under basal conditions, with 0.05 M HCl being perfused through the stomach, NKA (1.26 nmol min-1 kg-1) reduced gastric mucosal blood flow by about 25%, an effect that was abolished by SR 140,333 but not MEN 10,627 or ketotifen. 5. SR 140,333, MEN 10,627 or ketotifen had no significant effect on basal gastric mucosal blood flow nor did they modify the gastric mucosal hyperaemic reaction to acid back-diffusion. 6. The effect of NKA (1.26 nmol min-1 kg-1) in causing vasoconstriction and inhibiting the vasodilator response to acid back-diffusion was also seen when blood flow in the left gastric artery was measured with the ultrasonic transit time shift technique. 7. Arginine vasopressin (AVP, 0.1 nmol min-1 kg-1) induced gastric mucosal vasoconstriction under basal conditions but was unable to inhibit the dilator response to acid back-diffusion. 8. These data show that NKA has two fundamentally different effects on the gastric circulation. Firstly, NKA reduces gastric blood flow by activation of NK1 receptors. Secondly, NKA inhibits the gastric hyperaemic response to acid back-diffusion through an NK2 receptor-mediated mechanism. These two tachykinin effects appear to take place independently of each other since they are mediated by different receptors. This concept is further supported by the inability of AVP to mimic tachykinin inhibition of the gastric vasodilator response to acid back-diffusion.

Evaluation of frog gastric mucous secretion by 7T magnetic resonance imaging

This work describes a new method to evaluate the action of drugs on gastric mucus secretion by 7 T MRI. A polyethylene probe was inserted into the stomach of frogs, a water washing cycle was performed, air was inflated into the stomach, and the probe was removed. Drugs were administered topically by mixing them with the water used for stomach washing, and a series of images was collected. In untreated animals, a mucous layer emitting a high intensity signal covered the gastric mucosa. Atropine administration strongly reduced the mucous layer thickness. After pilocarpine administration, MRI images showed that the mucous layer was thicker than in controls. After metacholine administration, the thickness of the mucous layer was increased in comparison with both controls and pilocarpine-treated animals, in accord with the expected drug-induced increase of mucous secretion. Quantitative analysis of the mucous layer thickness on MRI images confirmed the above findings. In conclusion, these results indicate that MRI at 7 T is a sensitive in vivo screening test to evaluate the effect of drugs on gastric mucus secretion in absence of surgical manipulation, thereby enabling morphofunctional studies that cannot be performed by conventional methods.

In vivo morpho-functional study of rat gastric mucus secretion

BACKGROUND

Morpho-functional studies of gastric mucosa are hampered by the lack of a technique allowing direct in situ visualization of the mucus in small living laboratory animals.

METHODS

The material covering the gastric surface was studied in vivo in rats by magnetic resonance imaging (MRI) at 4.7 Tesla, and modification of its secretion was evaluated after pharmacological treatment.

RESULTS

In unstimulated animals, the glandular portion of the stomach was lined by a layer of material emitting a signal of high intensity. Administration of 16,16-dimethyl prostaglandin E2 caused an accumulation of this material within a maximum 30 min after the administration of the drug. At 45 min, gastric emptying occurred and at 60 min, the lumen was almost free of material emitting a signal of high intensity. An increase in the intensity of the signal emitted from the material filling the gastric lumen was found after pentagastrin injection. After 45 min, the intensity of the signal emitted from the material in the gastric lumen decreased. 1H localized spectroscopy showed that after injection of pentagastrin there was an increase in the water proton peak within the gastric lumen. About one hour after stimulation, the water proton peak returned to the basal value.

CONCLUSIONS

This study demonstrates that MRI displays gastric mucus in living small rodents and represents a sensitive screening test for pharmacological action on this structure, enabling morpho-functional studies.

Gastric emptying of solids but not liquids is decreased in rats with chronic renal failure

Severe gastric complications occur in uremic patients, yet few studies have addressed the effect of chronic renal failure (RF) on gastric physiology. In the present study, we investigated: (1) the effect of RF on gastric emptying of liquids and solids in awake rats, (2) the motor function in the gastric corpus, and (3) the role of nitric oxide in any alterations in gastric motor function in uremic rats. RF was induced by partial kidney infarction. RF had no effect on gastric emptying of liquids but significantly inhibited gastric emptying of solids by 68%. N-Nitro-L-arginine, an inhibitor of nitric oxide (NO) synthesis, had no effect on the reduced gastric emptying of solids in RF rats. RF rats showed an altered pattern of gastric motility compared to sham-operated rats. These data suggest that RF induced an inhibition of gastric emptying of solids, but not liquids. However, NO does not seem to play a role in this inhibition.

Prostaglandin E2 enhances gastric defense mechanisms against acid injury in uremic rats

BACKGROUND/AIMS

Uremia increases gastric mucosal H+ permeability and acid back-diffusion-related injury in rats. The aim of this study was to examine the effect of the synthetic gastroprotective compound 16,16-dimethyl prostaglandin E2 (16,16-dm PGE2) on the gastric barrier to acid injury in uremic rats.

METHODS

Chronic renal failure was induced by subtotal nephrectomy. Acid back-diffusion injury was induced by superfusion with 15% ethanol in 0.15N HCl and was assessed by image analysis. Intracellular pH, initial surface cell acidification rate, and thickness of mucous gel layer were measured with in vivo microscopy. Gastric mucosal blood flow was measured in separate experiments by laser-Doppler flowmetry.

RESULTS

Pretreatment with 16,16-dm PGE2 attenuated H+ back-diffusion and prevented the production of gross lesions. 16,16-dm PGE2 increased gastric mucous gel thickness, decreased initial acidification rate, and maintained intracellular pH homeostasis during exposure to luminal acid. Gastric mucosal blood flow was not changed during superfusion with a neutral buffer but increased during acid exposure in rats treated with 16,16-dm PGE2.

CONCLUSIONS

16,16-dm PGE2 attenuated H+ back-diffusion injury in uremic rats. This effect was associated with blunting of the initial decrease of intracellular pH and enhanced surface cell intracellular pH homeostasis during acid exposure. These effects were associated with an increased mucous gel layer thickness and an acid-related increase in blood flow.

Uremia in the rat affects gastric cell growth and differentiation

The aim of this study was to determine if hypertrophy of different tissues seen in uremic rats included gastrointestinal hypertrophy and an increase in parietal cell mass that might explain the increased acid secretion we previously reported. Chronic renal failure was induced by subtotal nephrectomy. Despite a lower total body weight, uremic rats had a significantly greater stomach weight (33%), corpus area (13%), corpus mucosal height (19%), and parietal (32%) and enterochromaffin-like (ECL, 54%) cell density, but a 16% decrease in mucous neck cell region height. These findings suggest that uremia leads to gastric stem cell stimulation with differentiation favoring parietal and ECL cells over mucous cells. In addition, in uremic rats there was an increase in height of the duodenal mucosa, but not of the ileal or transverse colon mucosa. In conclusion, the present study shows that uremia in the rat promotes hypertrophy of the stomach with cell differentiation favoring parietal cells over mucus cells. The increase in parietal cell mass may explain the increased acid secretion in these rats.

Isoproterenol enhances rat gastric mucosal barrier function in vivo

BACKGROUND

The mechanism by which topical isoproterenol protects the gastric mucosa from ethanol-induced injury is unclear; previous studies suggest that enhancement of mucosal blood flow may be contributory. Therefore, we investigated the role of isoproterenol pretreatment on rat gastric mucous gel layer thickness, mucosal blood flow, and surface cell intracellular pH.

METHODS

A portion of the gastric corpus of an anesthetized rat was isolated in a superfused chamber. Intracellular pH was measured with the fluorescent dye 5(6)-carboxyfluorescein diacetate, mucous gel thickness was measured by quantifying the distance between the focal planes of the epithelial cell and the gel surfaces, and mucosal blood flow was measured in separate experiments with a laser-Doppler flowmeter.

RESULTS

Pretreatment with topical isoproterenol markedly increased gastric mucous gel layer thickness, decreased surface cell initial acidification rates, and significantly enhanced the recovery of intracellular pH toward baseline values. Gastric mucosal blood flow was significantly higher in the isoproterenol-treated group compared with untreated controls, initially increasing, decreasing, and then increasing a second time during superfusion with acidic solutions.

CONCLUSIONS

Isoproterenol preserves gastric surface cell intracellular pH during acid superfusion. This effect may be a result of an increased thickness of the mucous layer, which delays proton entry into the surface cell, and an increase in mucosal blood flow in response to luminal acid, which appears to enhance recovery from intracellular acidosis.