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Petini M, Drigo M, Caldin M, Zoia A. Diagnostic predictivity of transtubular potassium gradient for primary hypoadrenocorticism in hyperkalemic dogs: a cross-sectional study. J Small Anim Pract 2023; 64:434-441. [PMID: 37037658 DOI: 10.1111/jsap.13613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 02/01/2023] [Accepted: 03/05/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVES Transtubular potassium gradient has never been evaluated in the diagnosis of primary hypoadrenocorticism in dogs. The objective of this study is to evaluate the diagnostic utility of transtubular potassium gradient for the diagnosis of primary hypoadrenocorticism in dogs with serum K+ > 5.5 mol/L. MATERIALS AND METHODS Cross-sectional study including dogs with primary hypoadrenocorticism and dogs with other disease. Differences in signalment and laboratory parameters between groups were assessed by binary logistic regression modelling. Variables significantly associated with primary hypoadrenocorticism were evaluated for their diagnostic accuracy of this condition by receiver operator characteristic curve analysis and by multivariable logistic regression analysis, respectively. RESULTS Dogs with primary hypoadrenocorticism (n=39) were significantly younger than hyperkalemic dogs without primary hypoadrenocorticism (n=41). Moreover they had higher serum and urinary concentrations of Na+ and Na+ :K+ , but lower transtubular potassium gradient than hyperkalemic dogs without hypoadrenocorticism. Serum Na+ (sNa+ ) had the highest diagnostic accuracy (area under the curve [AUC]: 0.87, 95% confidence interval, 0.78 to 0.96), followed by the transtubular potassium gradient (AUC: 0.81, 0.72 to 0.91), however the accuracy of the two AUCs was not statistically different. The transtubular potassium gradient-sNa+ additive index (i.e. transtubular potassium gradient+sNa+ /10) had a greater accuracy (AUC: 0.88, 0.79 to 0.94) than transtubular potassium gradient or sNa+ , although it was not statistically superior to the latter. The multivariable logistic regression model showed that transtubular potassium gradient (adjusted odds ratio [aOR]: 0.51, 0.3 to 0.84), sNa+ (aOR: 0.86, 0.78 to 0.95) and spayed female (aOR: 24.96, 2.32 to 267.66) were associated with primary hypoadrenocorticism. CLINICAL SIGNIFICANCE Transtubular potassium gradient-sNa+ additive index can contribute to decision-making on diagnosis of primary hypoadrenocorticism in dogs presenting with hyperkalaemia.
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Affiliation(s)
- M Petini
- Division of Internal Medicine, San Marco Veterinary Clinic, Via dell'Industria 3, Veggiano, Italy
| | - M Drigo
- Department of Animal Medicine, Production and Health, University of Padova, V.le dell'Università 16, 35020, Legnaro, Italy
| | - M Caldin
- San Marco Veterinary Laboratory, Via dell'Industria 3, Veggiano, Italy
| | - A Zoia
- Division of Internal Medicine, San Marco Veterinary Clinic, Via dell'Industria 3, Veggiano, Italy
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2
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Chiu CH, Hsuan CF, Lin SH, Hung YJ, Hwu CM, Hee SW, Lin SW, Fong SW, Hsieh PCH, Yang WS, Lin WC, Lee HL, Hsieh ML, Li WY, Lin JW, Hsu CN, Wu VC, Chuang GT, Chang YC, Chuang LM. ER ribosomal-binding protein 1 regulates blood pressure and potassium homeostasis by modulating intracellular renin trafficking. J Biomed Sci 2023; 30:13. [PMID: 36803854 PMCID: PMC9940419 DOI: 10.1186/s12929-023-00905-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/07/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Genome-wide association studies (GWASs) have linked RRBP1 (ribosomal-binding protein 1) genetic variants to atherosclerotic cardiovascular diseases and serum lipoprotein levels. However, how RRBP1 regulates blood pressure is unknown. METHODS To identify genetic variants associated with blood pressure, we performed a genome-wide linkage analysis with regional fine mapping in the Stanford Asia-Pacific Program for Hypertension and Insulin Resistance (SAPPHIRe) cohort. We further investigated the role of the RRBP1 gene using a transgenic mouse model and a human cell model. RESULTS In the SAPPHIRe cohort, we discovered that genetic variants of the RRBP1 gene were associated with blood pressure variation, which was confirmed by other GWASs for blood pressure. Rrbp1- knockout (KO) mice had lower blood pressure and were more likely to die suddenly from severe hyperkalemia caused by phenotypically hyporeninemic hypoaldosteronism than wild-type controls. The survival of Rrbp1-KO mice significantly decreased under high potassium intake due to lethal hyperkalemia-induced arrhythmia and persistent hypoaldosteronism, which could be rescued by fludrocortisone. An immunohistochemical study revealed renin accumulation in the juxtaglomerular cells of Rrbp1-KO mice. In the RRBP1-knockdown Calu-6 cells, a human renin-producing cell line, transmission electron and confocal microscopy revealed that renin was primarily retained in the endoplasmic reticulum and was unable to efficiently target the Golgi apparatus for secretion. CONCLUSIONS RRBP1 deficiency in mice caused hyporeninemic hypoaldosteronism, resulting in lower blood pressure, severe hyperkalemia, and sudden cardiac death. In juxtaglomerular cells, deficiency of RRBP1 reduced renin intracellular trafficking from ER to Golgi apparatus. RRBP1 is a brand-new regulator of blood pressure and potassium homeostasis discovered in this study.
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Affiliation(s)
- Chu-Hsuan Chiu
- grid.19188.390000 0004 0546 0241Graduate Institute of Medical Genomics and Proteomics, National Taiwan University, Taipei, 100 Taiwan ,grid.28665.3f0000 0001 2287 1366Institute of Biomedical Sciences, Academia Sinica, Taipei, 115 Taiwan
| | - Chin-Feng Hsuan
- grid.414686.90000 0004 1797 2180Division of Cardiology, Department of Internal Medicine, E-Da Hospital, Kaohsiung, 824410 Taiwan ,Division of Cardiology, Department of Internal Medicine, E-Da Dachang Hospital, Kaohsiung, 82445 Taiwan ,grid.411447.30000 0004 0637 1806School of Medicine, College of Medicine, I-Shou University, Kaohsiung, 840203 Taiwan
| | - Shih-Hua Lin
- grid.260565.20000 0004 0634 0356Graduate Institute of Medical Science, National Defense Medical Center, Taipei, 114 Taiwan ,grid.278247.c0000 0004 0604 5314Section of General Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, 111 Taiwan
| | - Yi-Jen Hung
- grid.260565.20000 0004 0634 0356Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, 100 Taiwan
| | - Chii-Min Hwu
- grid.260539.b0000 0001 2059 7017Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, 112 Taiwan ,grid.278244.f0000 0004 0638 9360Division of Nephrology, Department of Medicine, Tri-Service General Hospital, Taipei, 114 Taiwan
| | - Siow-Wey Hee
- grid.412094.a0000 0004 0572 7815Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100 Taiwan
| | - Shu-Wha Lin
- grid.19188.390000 0004 0546 0241Division of Genomic Medicine, Research Center for Medical Excellence, Transgenic Mouse Models Core, National Taiwan University, Taipei, 100 Taiwan
| | - Sitt-Wai Fong
- grid.28665.3f0000 0001 2287 1366Institute of Biomedical Sciences, Academia Sinica, Taipei, 115 Taiwan
| | - Patrick Ching-Ho Hsieh
- grid.28665.3f0000 0001 2287 1366Institute of Biomedical Sciences, Academia Sinica, Taipei, 115 Taiwan
| | - Wei-Shun Yang
- grid.19188.390000 0004 0546 0241Graduate Institute of Medical Genomics and Proteomics, National Taiwan University, Taipei, 100 Taiwan ,grid.412094.a0000 0004 0572 7815Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, 302 Taiwan
| | - Wei-Chou Lin
- grid.412094.a0000 0004 0572 7815Department of Pathology, National Taiwan University Hospital, Taipei, 100 Taiwan
| | - Hsiao-Lin Lee
- grid.412094.a0000 0004 0572 7815Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100 Taiwan
| | - Meng-Lun Hsieh
- grid.412094.a0000 0004 0572 7815Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100 Taiwan ,grid.15276.370000 0004 1936 8091Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL 32610 USA
| | - Wen-Yi Li
- grid.412094.a0000 0004 0572 7815Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, 640 Taiwan
| | - Jou-Wei Lin
- grid.412094.a0000 0004 0572 7815Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, 640 Taiwan
| | - Chih-Neng Hsu
- grid.412094.a0000 0004 0572 7815Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, 640 Taiwan
| | - Vin-Cent Wu
- grid.412094.a0000 0004 0572 7815Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100 Taiwan
| | - Gwo-Tsann Chuang
- grid.19188.390000 0004 0546 0241Graduate Institute of Medical Genomics and Proteomics, National Taiwan University, Taipei, 100 Taiwan ,grid.412094.a0000 0004 0572 7815Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, 100 Taiwan
| | - Yi-Cheng Chang
- Graduate Institute of Medical Genomics and Proteomics, National Taiwan University, Taipei, 100, Taiwan. .,Institute of Biomedical Sciences, Academia Sinica, Taipei, 115, Taiwan. .,Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan. .,Graduate Institute of Molecular Medicine, National Taiwan University, Taipei, 100, Taiwan.
| | - Lee-Ming Chuang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan. .,Graduate Institute of Molecular Medicine, National Taiwan University, Taipei, 100, Taiwan. .,Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, 100, Taiwan.
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3
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A case of idiopathic nodular glomerulosclerosis successfully treated by intensive blockade of the renin–angiotensin–aldosterone system. CEN Case Rep 2022. [PMID: 36574195 PMCID: PMC10393922 DOI: 10.1007/s13730-022-00766-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Idiopathic nodular glomerulosclerosis has a poor renal prognosis and is characterized by diffuse nodular glomerulosclerotic lesions in the absence of diabetic mellitus. Here, we report the case of a 69-year-old woman with no smoking history who developed renal dysfunction and proteinuria in the absence of overt diabetes or obesity. A biopsy specimen showed nodular mesangial sclerosis with arteriolar hyalinosis and severe large-vessel arteriosclerosis, leading to a diagnosis of idiopathic nodular glomerulosclerosis. Addition of esaxerenone to her existing renin-angiotensin-aldosterone inhibitor therapy led to a rapid decrease in the proteinuria levels and the maintenance of renal function without any complications for more than a year. The results suggest that intensive renin-angiotensin-aldosterone blockade might be an effective treatment for idiopathic nodular glomerulosclerosis.
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4
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Gupta N, Prasad P. Hyperkalemia in diabetes: newer insights into mechanism and treatment. Postgrad Med J 2021; 98:e45. [PMID: 37063000 DOI: 10.1136/postgradmedj-2021-140226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Nimish Gupta
- Nephrology, Metro Heart Institute with Multispeciality, Faridabad, Haryana, India
| | - Pallavi Prasad
- Nephrology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India
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5
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Massolini BD, Contieri SSG, Lazarini GS, Bellacosa PA, Dobre M, Petroianu G, Brateanu A, Campos LA, Baltatu OC. Therapeutic Renin Inhibition in Diabetic Nephropathy-A Review of the Physiological Evidence. Front Physiol 2020; 11:190. [PMID: 32231590 PMCID: PMC7082742 DOI: 10.3389/fphys.2020.00190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/19/2020] [Indexed: 11/13/2022] Open
Abstract
The purpose of this systematic review was to investigate the scientific evidence to support the use of direct renin inhibitors (DRIs) in diabetic nephropathy (DN). MEDLINE was searched for articles reported until 2018. A standardized dataset was extracted from articles describing the effects of DRIs on plasma renin activity (PRA) in DN. A total of three clinical articles studying PRA as an outcome measure for DRIs use in DN were identified. These clinical studies were randomized controlled trials (RCTs): one double-blind crossover, one post hoc of a double-blind and placebo-controlled study, and one open-label and parallel-controlled study. Two studies reported a significant decrease of albuminuria associated with PRA reduction. One study had a DRI as monotherapy compared with placebo, and two studies had DRI as add-in to an angiotensin II (Ang II) receptor blocker (ARB). Of 10,393 patients with DN enrolled in five studies with DRI, 370 (3.6%) patients had PRA measured. Only one preclinical study was identified that determined PRA when investigating the effects of aliskiren in DN. Moreover, most of observational preclinical and clinical studies identified report on a low PRA or hyporeninemic hypoaldosteronism in DM. Renin inhibition has been suggested for DN, but proof-of-concept studies for this are scant. A small number of clinical and preclinical studies assessed the PRA effects of DRIs in DN. For a more successful translational research for DRIs, specific patient population responsive to the treatment should be identified, and PRA may remain a biomarker of choice for patient stratification.
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Affiliation(s)
- Bianca Domingues Massolini
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil
| | - Stephanie San Gregorio Contieri
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil
| | - Giulia Severini Lazarini
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil
| | - Paula Antoun Bellacosa
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil
| | - Mirela Dobre
- Division of Nephrology and Hypertension, University Hospitals, Cleveland, OH, United States
| | - Georg Petroianu
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Andrei Brateanu
- Medicine Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Luciana Aparecida Campos
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil.,College of Health Sciences, Abu Dhabi University, Abu Dhabi, United Arab Emirates
| | - Ovidiu Constantin Baltatu
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil.,College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
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6
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Lemus R, Tobias JD. Hyponatremia and Hyporeninemic-Hypoaldosteronism in a Pediatric Intensive Care Unit Patient. J Med Cases 2020; 11:100-102. [PMID: 34434375 PMCID: PMC8383575 DOI: 10.14740/jmc3457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/08/2020] [Indexed: 11/11/2022] Open
Abstract
Hyponatremia is one of the most commonly encountered electrolyte abnormalities encountered in the pediatric world. Defined as a serum or plasma sodium less than 135 mEq/L, the etiology of hyponatremia is one that can typically be determined by performance of a thorough history. However, occasionally the etiology of a patient's hyponatremia is more elusive and determined only after laboratory evaluation. We present a 6-year-old girl with a complex medical history including spinal muscular atrophy, tracheostomy and ventilator dependence, who was admitted to the pediatric intensive care unit for treatment and evaluation of seizures with hyponatremia that was initially thought to be due to syndrome of inappropriate anti-diuretic hormone or cerebral salt wasting. However, during her hospital course, it was determined that the hyponatremia was more indicative of a rarer and much less common cause of hyponatremia, hyporeninemic-hypoaldosteronism. The physiological factors controlling serum sodium are reviewed, the etiologies of hyponatremia are presented and the treatment of hyporeninemic-hypoaldosteronism is discussed.
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Affiliation(s)
- Rafael Lemus
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
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7
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Chelaghma N, Oyibo SO. Hyporeninemic hypoaldosteronism in a patient with diabetes mellitus: an unforgettable case report. Int Med Case Rep J 2018; 11:69-72. [PMID: 29662328 PMCID: PMC5892611 DOI: 10.2147/imcrj.s158628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A 58-year-old man presented with a 3-year history of chronic and intermittent hyperkalemia requiring recurrent attendances to the emergency department for urgent treatment. His medical history included secondary diabetes mellitus following a bout of acute pancreatitis and a previous splenectomy for a spontaneous splenic rupture. He also had a history of prolonged use of non-steroidal anti-inflammatory drugs for back pain and painful neuropathy. He was not on any medication or diet that would cause a raised serum potassium level and his renal function was normal. He was on a basal-bolus insulin regimen but his diabetes control had been poor for several years. As the hyperkalemia had gone on for so long in the presence of normal renal function, he went on to have further tests. Adrenal insufficiency had been ruled out following a short Synacthen test. Further investigations revealed low serum aldosterone levels and inappropriately low serum renin levels in the presence of hyperkalemia. This was suggestive of hyporeninemic hypoaldosteronism (HH). He was then treated with fludrocortisone and furosemide and his serum potassium levels remained normal. Additionally, he did not require any more emergency admissions to treat hyperkalemia thereafter. It was concluded that the HH-induced hyperkalemia was caused by diabetes mellitus or due to a combination of diabetes and prolonged use of non-steroidal anti-inflammatory drugs. The absence of renal impairment may have contributed to the delay in diagnosis. HH is a commonly overlooked cause of hyperkalemia. This case highlights the fact that it should always be suspected when unexplained hyperkalemia is found in patients with only mild-moderately impaired renal function, especially in the presence of diabetes mellitus.
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Affiliation(s)
- Naziha Chelaghma
- Department of Diabetes & Endocrinology, Peterborough City Hospital, Peterborough, UK
| | - Samson O Oyibo
- Department of Diabetes & Endocrinology, Peterborough City Hospital, Peterborough, UK
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8
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9
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Abstract
Aging is associated with structural and functional changes in the kidney. Structural changes include glomerulosclerosis, thickening of the basement membrane, increase in mesangial matrix, tubulointerstitial fibrosis and arteriosclerosis. Glomerular filtration rate is maintained until the fourth decade of life, after which it declines. Parallel reductions in renal blood flow occur with redistribution of blood flow from the cortex to the medulla. Other functional changes include an increase in glomerular basement permeability and decreased ability to dilute or concentrate urine.
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Affiliation(s)
- Zeina Karam
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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10
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Pater C, Bhatnagar D, Berrou JP, Luszick J, Beckmann K. A novel approach to treatment of hypertension in diabetic patients - a multicenter, double-blind, randomized study comparing the efficacy of combination therapy of Eprosartan versus Ramipril with low-dose Hydrochlorothiazide and Moxonidine on blood pressure levels in patients with hypertension and associated diabetes mellitus type 2 - rationale and design [ISRCTN55725285]. CURRENT CONTROLLED TRIALS IN CARDIOVASCULAR MEDICINE 2004; 5:9. [PMID: 15461784 PMCID: PMC524514 DOI: 10.1186/1468-6708-5-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2004] [Accepted: 10/01/2004] [Indexed: 01/07/2023]
Abstract
Hypertension and diabetes mellitus are closely interrelated and coexist in as many as two-thirds of patients with type 2 diabetes. The consequent risk of such an association is an accelerated development of atherosclerotic cardiovascular disease and nephropathy complications.In choosing an antihypertensive agent, effectiveness needs to be accompanied by favourable metabolic, cardioprotective, and nephroprotective properties. Given the multifactorial nature of hypertension, the approach that has gained widespread agreement is treatment with more than one agent. Agents with different mechanisms of action increase antihypertensive efficacy because of synergistic impacts on the cardiovascular system. Combination therapy allows the use of lower doses of each antihypertensive agent which accounts for the excellent tolerability of combination products.The aim of the present study is to quantify the efficacy of combination therapy of Eprosartan 600 mg respectively Ramipril 5 mg with low-dose Hydrochlorothiazide and Moxonidine on blood pressure levels in patients with essential hypertension and associated diabetes mellitus type 2.The use of monotherapy (Eprosartan or Ramipril) followed by addition of low-dose Hydrochlorothiazide as second agent and of Moxonidine as a third agent will be individualized to the severity of hypertension in the particular patient and to his/her degree of response to current treatment.
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Affiliation(s)
- Cornel Pater
- Department of Cardiovascular Clinical Development, Solvay Pharmaceuticals GmbH, Hannover, Germany
| | | | - Jean-Pascal Berrou
- Global Product Strategy Department, Solvay Pharmaceuticals GmbH, Hannover Germany
| | - Joachim Luszick
- Department of Cardiovascular Clinical Development, Solvay Pharmaceuticals GmbH, Hannover, Germany
| | - Katrin Beckmann
- Department of Cardiovascular Clinical Development, Solvay Pharmaceuticals GmbH, Hannover, Germany
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11
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Moore MA. Drugs that interrupt the renin-angiotensin system should be among the preferred initial drugs to treat hypertension. J Clin Hypertens (Greenwich) 2003; 5:137-44. [PMID: 12671327 PMCID: PMC8101851 DOI: 10.1111/j.1524-6175.2003.01040.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2001] [Revised: 04/01/2002] [Accepted: 04/11/2002] [Indexed: 12/01/2022]
Abstract
The goal of antihypertensive therapy is to provide effective treatment that can be sustained lifelong, while lowering elevated blood pressure and preventing hypertensive end-organ damage and mortality. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II antagonists (AIIAs) control blood pressure as well as other available classes of antihypertensive drugs. The ACE inhibitors have been demonstrated to reduce the incidence of stroke, reverse left ventricular hypertrophy, and improve congestive heart failure symptomatology and mortality to a similar degree as diuretics and beta-adrenergic blockers. ACE inhibitors reduce postmyocardial infarction recurrence, improve congestive heart failure symptomatology and mortality, and slow the progression of glomerular renal disease. The AIIAs reverse left ventricular hypertrophy. Several of these agents have been shown to improve congestive heart failure symptomology and mortality, to reduce the occurrence of early atherosclerotic vascular disease, and to slow the progression of renal failure in type 2 diabetes mellitus nephropathy. One AIIA has reduced the incidence of end-stage renal disease in non-insulin-dependence diabetes mellitus nephropathy over 3 years. Ideally, antihypertensive therapy should maintain or improve the patients quality of life without creating side effects or adverse laboratory effects. Among the available nine classes of antihypertensive drugs, ACE inhibitors and the AIIAs come close to meeting the description of an ideal drug. AIIAs and ACE inhibitors, two classes of antihypertensive drugs that reduce the activity of the renin-angiotensin II system, should be among the preferred first-step drugs for the treatment of hypertension.
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Affiliation(s)
- Michael A Moore
- Hypertension Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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12
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Singh S, Bohn D, Carlotti APCP, Cusimano M, Rutka JT, Halperin ML. Cerebral salt wasting: truths, fallacies, theories, and challenges. Crit Care Med 2002; 30:2575-9. [PMID: 12441772 DOI: 10.1097/00003246-200211000-00028] [Citation(s) in RCA: 152] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The reported prevalence of cerebral salt wasting has increased in the past three decades. A cerebral lesion and a large natriuresis without a known stimulus to excrete so much sodium (Na ) constitute its essential two elements. OBJECTIVES To review the topic of cerebral salt wasting. There is a diagnostic problem because it is difficult to confirm that a stimulus for the renal excretion of Na is absent. DESIGN Review article. INTERVENTION None. MAIN RESULTS Three fallacies concerning cerebral salt wasting are stressed: first, cerebral salt wasting is a common disorder; second, hyponatremia should be one of its diagnostic features; and third, most patients have a negative balance for Na when the diagnosis of cerebral salt wasting is made. Three causes for the large natriuresis were considered: first, a severe degree of extracellular fluid volume expansion could down-regulate transporters involved in renal Na resorption; second, an adrenergic surge could cause a pressure natriuresis; and third, natriuretic agents might become more potent when the effective extracellular fluid volume is high. CONCLUSIONS Cerebral salt wasting is probably much less common than the literature suggests. With optimal treatment in the intensive care unit, hyponatremia should not develop.
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Affiliation(s)
- Sheila Singh
- Department of Pediatric Neurosurgery, Hospital for Sick Children, Toronto, Canada
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13
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Moore MA. Choosing initial antihypertensive drug therapy for the uncomplicated hypertensive patient. J Clin Hypertens (Greenwich) 2001; 3:37-44. [PMID: 11416681 PMCID: PMC8101857 DOI: 10.1111/j.1524-6175.2001.990830.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2000] [Accepted: 06/21/2000] [Indexed: 11/29/2022]
Abstract
Choosing the initial antihypertensive drug for the uncomplicated hypertensive patient is an important and frequent event for the primary care physician. Patients' first experience with antihypertensive drug therapy will likely affect their long-term perception of hypertension treatment. The choice should be made on the basis of sound scientific data and from the patient's perspective and needs. The drug should be taken once a day, should have proven efficacy in hypertension control and cardiovascular morbidity and mortality reduction, and should have as few side effects as possible. Low-dose thiazide diuretics meet this description, although the need to monitor electrolytes may make them less than ideal. The angiotensin II receptor antagonist class, with side-effects similar to those of placebo in controlled trials, is the most attractive from the patient's perspective, although outcome trial data do not yet exist proving that hypertension treatment with angiotensin II receptor antagonists reduces cardiovascular events. The angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists, with their low side-effect profiles and unique effects on vascular remodeling, are attractive second choices to combine with a diuretic if needed, although low-dose diuretic/Beta blocker combinations have also been shown to lower blood pressure with minimal side effects. At present, ensuring adequate long-term hypertension control is the most important aspect of hypertensive care, and which antihypertensive drug(s) the physician chooses can greatly affect the hypertensive patient's ability to achieve and to maintain long-term blood pressure control. (c)2001 by Le Jacq Communications, Inc.
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Affiliation(s)
- M A Moore
- Hypertension Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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14
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Abstract
Aldosterone participates in blood volume and serum potassium homeostasis, which in turn regulate aldosterone secretion by the zona glomerulosa of the adrenal cortex. Autonomous aldosterone hypersecretion leads to hypertension and hypokalemia. Improved screening techniques have led to a re-evaluation of the frequency of primary aldosteronism among adults with hypertension, recognizing that normokalemic cases are more frequent than was previously appreciated. The genetic basis of glucocorticoid remediable aldosteronism has been elucidated and adequately explains most of the pathophysiologic features of this disorder. A new form of familial aldosteronism has been described, familial hyperaldosteronism type II; linkage analysis and direct mutation screening has shown that this disorder is unrelated to mutations in the genes for aldosterone synthase or the angiotensin II receptor. The features of aldosterone hypersecretion may be due to non-aldosterone-mediated mineralocorticoid excess. These include two causes of congenital adrenal hyperplasia (11 beta-hydroxylase deficiency and 17 alpha-hydroxylase deficiency), the syndrome of apparent mineralocorticoid excess (AME) due to 11 beta-hydroxysteroid dehydrogenase (11 beta-HSD) deficiency, primary glucocorticoid resistance, Liddle's syndrome due to activating mutations of the renal epithelial sodium channel, and exogenous sources of mineralocorticoid, such as licorice, or drugs, such as carbenoxolone. The features of mineralocorticoid excess are also often seen in Cushing's syndrome. Hypoaldosteronism may lead to hypotension and hyperkalemia. Hypoaldosteronism may be due to inadequate stimulation of aldosterone secretion (hyporeninemic hypoaldosteronism), defects in adrenal synthesis of aldosterone, or resistance to the ion transport effects of aldosterone, such as are seen in pseudohypoaldosteronism type I (PHA I). PHA I is frequently due to mutations involving the amiloride sensitive epithelial sodium channel. Gordon's syndrome (PHA type II) is due to resistance to the kaliuretic but not sodium reabsorptive effects of aldosterone for which the genetic basis is still unknown. This review aims to provide a survey of the clinical disorders of aldosterone excess and deficiency and their clinical management, with a focus on primary aldosteronism and isolated aldosterone deficiency.
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Affiliation(s)
- D J Torpy
- National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
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15
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Miller M. Fluid and electrolyte homeostasis in the elderly: physiological changes of ageing and clinical consequences. BAILLIERE'S CLINICAL ENDOCRINOLOGY AND METABOLISM 1997; 11:367-87. [PMID: 9403127 DOI: 10.1016/s0950-351x(97)80347-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Characteristic of the normal ageing process are changes in the renal, hormonal and thirst regulatory systems involved in the control of sodium and water balance. In the presence of disease or drug use, the ageing changes put the elderly person at increased risk of either sodium retention or loss and of water retention or loss. Clinically, these alterations in water and sodium balance are commonly expressed as either hyponatraemia or hypernatraemia with central nervous system dysfunction as the symptomatic expression. Thus, the impaired homeostasis of the many systems affecting fluid balance in the elderly is readily influenced by many of the disease states and medications which are often present in the elderly with resultant adverse clinical consequences. Awareness of these age-associated circumstances can allow the physician to anticipate the impact of illnesses and drugs and to implement a rational approach to therapeutic intervention and management.
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Affiliation(s)
- M Miller
- Department of Medicine, Levindale Hebrew Geriatric Center and Hospital, Baltimore, MD 21215, USA
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Malik WA, Labib MH, Irfan H. Hyporeninaemic hypoaldosteronism and systemic amyloidosis. Ann Clin Biochem 1995; 32 ( Pt 6):593-4. [PMID: 8579295 DOI: 10.1177/000456329503200614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- W A Malik
- Department of Medicine for the Elderly, Guest Hospital, Dudley, West Midlands, UK
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17
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18
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Abstract
Renal stone formation is uncommon in patients with type IV renal tubular acidosis (RTA). This study was undertaken to explore the urinary biochemical and physicochemical factors in patients with type IV RTA in order to elucidate the mechanisms that protect them from renal stone formation. Twelve subjects with type IV RTA and 12 matched subjects with a similar degree of kidney impairment but without RTA were studied. Both groups of patients had low urinary excretion of calcium, phosphorus, uric acid, and citrate, probably reflective of kidney impairment. Patients with type IV RTA had a significantly lower urinary pH and urinary excretion of calcium than their matched controls. Hypocitraturia was present in both groups without any significant difference between them. This study suggests that the major protection from renal stone formation in type IV RTA results from impaired renal function and ensuing reduction in renal excretion of stone-forming substances, such as calcium and uric acid.
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Affiliation(s)
- J Uribarri
- Department of Medicine, Mount Sinai School of Medicine, New York, NY
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19
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Abstract
Renal tubular function was assessed in seven patients with methylmalonic acidaemia not responsive to vitamin B12. Five patients failed to concentrate their urine normally and in these patients the glomerular filtration rate was also reduced. Fractional excretion of sodium was increased in four patients, fractional excretion of potassium in one patient and in three there was a decreased tubular reabsorption of phosphate. Although possibly representing primary tubular damage these findings were thought to be consistent with adaptive changes secondary to the reduced glomerular filtration rate. Two patients had evidence of a defect of urinary acidification and several had a degree of hyporeninaemic hypoaldosteronism suggesting type 4 renal tubular acidosis. In one patient with a mild variant no renal disease was detected. Decreased renal function and tubular abnormalities were common in patients with methylmalonic acidaemia. It is likely that they are linked and essentially secondary to the tubulo-interstitial nephritis that is histologically demonstrable on renal biopsy. The failure of urinary concentrating ability and the disturbed urine acidification will contribute to the metabolic derangement during episodes of decompensation.
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Affiliation(s)
- C T D'Angio
- Department of Child Health, Hospital for Sick Children, London, UK
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20
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Don BR, Schambelan M. Hyperkalemia in acute glomerulonephritis due to transient hyporeninemic hypoaldosteronism. Kidney Int 1990; 38:1159-63. [PMID: 2074657 DOI: 10.1038/ki.1990.327] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Transient hyperkalemia has been reported to occur in patients with acute glomerulonephritis, but the pathogenetic mechanism has not been investigated systematically. We studied the mechanism of hyperkalemia (5.7 to 6.7 mmol/liter) in four men with post-infectious glomerulonephritis. All four patients had clinical findings consistent with acute glomerulonephritis (edema, hypertension, proteinuria, hematuria, and an elevated ASO titer) and a renal biopsy performed in three of the patients confirmed the diagnosis. In comparison to normal subjects (N = 18), plasma aldosterone (5.4 +/- 1.6 vs. 22.8 +/- 2.6 ng/dl, P less than 0.005) and plasma renin activity (0.3 +/- 0.2 vs. 4.3 +/- 0.6 ng/ml/hr, P less than 0.005) were reduced. Hyperkalemia resolved within one to two weeks in two patients as the nephritis resolved and diuresis ensued, and aldosterone and renin levels obtained at follow-up visits were normal. Hyperkalemia persisted despite furosemide-induced diuresis in the other two patients, but resolved with fludrocortisone treatment. Thus, hyperkalemia in patients with acute glomerulonephritis is a manifestation, in part, of hyporeninemic hypoaldosteronism. It is ameliorated by mineralocorticoid therapy and improves spontaneously with resolution of the glomerulonephritis.
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Affiliation(s)
- B R Don
- Medical Service, San Francisco General Hospital Medical Center, California
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21
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Uribarri J, Oh MS, Carroll HJ. Hyperkalemia in diabetes mellitus. THE JOURNAL OF DIABETIC COMPLICATIONS 1990; 4:3-7. [PMID: 2141843 DOI: 10.1016/0891-6632(90)90057-c] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Potassium filtered at the glomerulus is almost completely reabsorbed before the distal tubule; it must therefore be secreted into the collecting duct. The rate of potassium secretion is determined by a number of factors, notably aldosterone, distal sodium delivery, and serum potassium. Normal serum potassium is maintained by the interplay of passive leak of potassium from the cells and its active return to the cells. Transmembrane potassium distribution is influenced largely by acid-base equilibrium and hormones including insulin and catecholamines. In the diabetic with ketoacidosis hyperkalemia, in the face of potassium depletion, is attributable to reduced renal function, acidosis, release of potassium from cells due to glycogenolysis, and lack of insulin. Chronic hyperkalemia in diabetics is most often attributable to hyporeninemic hypoaldosteronism but other conditions including urinary tract obstruction may also contribute. A variety of clinical situations (e.g., volume depletion) and drugs (e.g., nonsteroidal antiinflammatory agents, and heparin) may acutely provoke hyperkalemia in susceptible individuals.
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Affiliation(s)
- J Uribarri
- Department of Medicine, SUNY, Health Science Center, Brooklyn 11203
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22
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Affiliation(s)
- T C Williams
- University of Cincinnati College of Medicine, Department of Internal Medicine, OH 45267
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23
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Abstract
Potassium output from the body is regulated by renal excretion, which takes place predominantly in the late distal and cortical collecting tubules. The accepted model for potassium secretion implies the accumulation of potassium into the cell by the activity of basolateral Na-K-ATPase and its exit through voltage-dependent conductive channels. The factors regulating renal potassium secretion are potassium intake, distal urinary flow, systemic acid-base equilibrium, aldosterone, antidiuretic hormone and, probably, epinephrine. Renal handling of potassium is best studied by the response to the acute administration of furosemide. This loop diuretic not only increases sodium and chloride excretion but also enhances potassium and hydrogen ion excretion and stimulates the renin-aldosterone axis. The term "renal tubular hyperkalaemia" refers to a tubular dysfunction where the hyperkalaemia is disproportionate to any reduction in glomerular filtration rate (GFR) and not due primarily or solely to aldosterone deficiency or to drugs impairing either mineralocorticoid action or tubular transport. The syndromes of renal tubular hyperkalaemia mainly observed in childhood are "chloride shunt" syndrome, hyporeninaemic hypoaldosteronism and primary or secondary pseudohypoaldosteronism. Differential diagnosis between these conditions is easily made if attention is paid to the level of GFR, presence of sodium wasting, activity of the renin-aldosterone axis and renal response to acute administration of furosemide.
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Kalin MF, Poretsky L, Seres DS, Zumoff B. Hyporeninemic hypoaldosteronism associated with acquired immune deficiency syndrome. Am J Med 1987; 82:1035-8. [PMID: 3555065 DOI: 10.1016/0002-9343(87)90171-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Four patients with the acquired immune deficiency syndrome (AIDS) and persistent unexplained hyperkalemia were studied. Testing with cosyntropin (0.25 mg intravenously) revealed normal baseline and stimulated cortisol levels and adequate aldosterone stimulation. The baseline aldosterone level was low for the degree of hyperkalemia. Renin/aldosterone stimulation testing was performed by intravenous injection of 80 mg of furosemide followed by four hours of upright posture. This study showed low baseline renin and aldosterone levels and inadequate renin and aldosterone stimulation. Three patients were subsequently treated with fludrocortisone (0.1 to 0.2 mg per day), with normalization of serum potassium levels. It is concluded that hyporeninemic hypoaldosteronism is responsible for hyperkalemia in some patients with AIDS and that treatment with fludrocortisone is effective in these cases.
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Batlle DC. Sodium-dependent urinary acidification in patients with aldosterone deficiency and in adrenalectomized rats: effect of furosemide. Metabolism 1986; 35:852-60. [PMID: 3747842 DOI: 10.1016/0026-0495(86)90228-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Urinary acidification during metabolic acidosis and in response to stimulation of sodium-dependent hydrogen ion secretion using furosemide administration was evaluated in 12 patients with hyperkalemic hyperchloremic metabolic acidosis associated with mild chronic renal insufficiency and aldosterone deficiency. During spontaneous metabolic acidosis, the urine of all patients was acidic (pH less than 5.5), but ammonium excretion was markedly reduced (6.6 +/- 1.3 mu Eq/min) comprising only about 20% of net acid excretion (30.5 +/- 5.7 mu Eq/min). Furosemide (80 mg orally) resulted in a further fall in urine pH (from 5.29 +/- 0.06 to 4.97 +/- 0.09, P less than 0.02) and a significant increase in net acid excretion (from 30 +/- 5.8 to 38 +/- 5.1 mu Eq/min, P less than 0.02) while plasma aldosterone did not change (from 9.8 +/- 1.7 to 9.7 +/- 1.6 micrograms/dL). To investigate whether the acute stimulatory effect of furosemide on distal acidification requires some degree of mineralocorticoid activity, studies were conducted in adrenalectomized rats. The fall in urine pH and the increase in net acid excretion elicited by furosemide in adrenalectomized rats were comparable to those observed in adrenal-intact animals (5.37 +/- 0.10 v 5.67 +/- 0.11 and 0.43 +/- 0.08 v 0.41 +/- 0.06 mu Eq/min, respectively). In contrast, in adrenalectomized rats given amiloride to inhibit sodium transport in the cortical collecting tubule, furosemide failed to lower urine pH (6.44 +/- 0.23) and to increase net acid excretion (0.07 +/- 0.06 mu Eq/min). These findings demonstrate that furosemide enhances hydrogen ion secretion in the absence of aldosterone provided that sodium-transport in the cortical collecting tubule is not impaired.(ABSTRACT TRUNCATED AT 250 WORDS)
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Rodríguez-Soriano J, Vallo A, Sanjurjo P, Castillo G, Oliveros R. Hyporeninemic hypoaldosteronism in children with chronic renal failure. J Pediatr 1986; 109:476-82. [PMID: 3528445 DOI: 10.1016/s0022-3476(86)80121-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The syndrome of hyporeninemic hypoaldosteronism (SHH) is not infrequent in adults with chronic renal failure caused by chronic tubulointerstitial nephritis, but it has been reported rarely in children. We present a systematic study of the interrelation between renal excretion of potassium and the renin-aldosterone axis in 23 children with CRF of different and unselected causes. Twenty children with chronic renal failure never had hyperkalemia, and both renin and aldosterone were normally stimulated by intravenous administration of furosemide, whereas three patients had moderate hyperkalemia (serum potassium concentration between 5.3 and 5.6 mEq/L) and failed to raise plasma renin activity and aldosterone values in response to furosemide. There three patients with SHH had lower basal and stimulated values of fractional potassium excretion than did patients with normokalemic chronic renal failure. Fractional potassium excretion was curvilinearly related to glomerular filtration rate (GFR), but in all three patients with SHH it was lower than expected for the level of GFR present. Fractional sodium excretion was also related to GFR, but no abnormalities were found. Two patients had hyperchloremic metabolic acidosis. After furosemide administration, they excreted an acid urine with low ammonium content, features characteristic of type 4 or hyperkalemic renal tubular acidosis. Prostaglandin E2 excretion was also significantly related to GFR, and appeared appropriate in two patients with SHH. The identification of three patients with SHH among 23 with chronic renal failure of unselected causes suggests that this entity is not rare in childhood.
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27
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Nadler JL, Lee FO, Hsueh W, Horton R. Evidence of prostacyclin deficiency in the syndrome of hyporeninemic hypoaldosteronism. N Engl J Med 1986; 314:1015-20. [PMID: 3515183 DOI: 10.1056/nejm198604173141604] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Hyporeninemic hypoaldosteronism is an important cause of hyperkalemia and is characterized by low renin secretion. We found that prostacyclin, a potent vasodilator and renin secretagogue, was markedly reduced--as reflected by its stable urinary metabolite 6-keto-prostaglandin F1 alpha--in seven patients with hyporeninemic hypoaldosteronism as compared with seven matched controls with renal insufficiency and as compared with 12 normal volunteers (mean +/- SE, 42 +/- 7 vs. 185 +/- 37 and 164 +/- 20 ng per gram of creatinine, respectively; P less than 0.001). In contrast, renal prostaglandin E2 excretion was similar in all three groups. A low-dose infusion of calcium or norepinephrine (known stimulants of prostacyclin) increased renal prostacyclin release in normal subjects and controls with renal insufficiency. Neither agonist, however, increased the low basal prostacyclin excretion in the patients (49.6 +/- 11 [basal] vs. 62 +/- 20 [norepinephrine] and 47.5 +/- 16 [calcium]; P greater than 0.8). To evaluate the functional importance of the altered prostacyclin production, we studied the responses of renal blood flow and blood pressure to the calcium infusion. The calcium infusion did not alter blood pressure or renal blood flow in the normal subjects or the controls with renal insufficiency. In contrast, the same dose of calcium in the patients with hyporeninemic hypoaldosteronism produced a rise in mean blood pressure (from 91 +/- 6 to 104 +/- 8 mm Hg, P less than 0.05) and a fall in renal blood flow (from 673 +/- 58 to 560 +/- 42 ml per minute per 1.73 m2, P less than 0.05). These results indicate that a deficiency of prostacyclin could explain the low active-renin concentration and altered vasomotor tone seen in hyporeninemic hypoaldosteronism.
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Melby JC. Diagnosis and treatment of primary aldosteronism and isolated hypoaldosteronism. CLINICS IN ENDOCRINOLOGY AND METABOLISM 1985; 14:977-95. [PMID: 3002681 DOI: 10.1016/s0300-595x(85)80085-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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29
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Abstract
The investigation of syndromes of mineralocorticoid excess and deficiency has been reviewed. For screening for primary aldosteronism, repeated measures of plasma potassium on high sodium intake is the most practicable method. Further investigation should include saline infusion and, in cases of doubt, fludrocortisone/sodium loading. Differential diagnosis of adenoma from hyperplasia is best achieved by the aldosterone response to posture, CT scanning and, if necessary, adrenal venous catheterization. Suitable techniques for the investigation of secondary aldosteronism of unknown cause and for primary and secondary hypoaldosteronism are described, as well as the adjustment of dosage for replacement therapy where mineralocorticoid secretion is deficient.
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Padfield PL, Grekin RJ, Nicholls MG. Clinical syndromes associated with disorders of renal tubular chloride transport: excess and deficiency of a circulating factor? Med Hypotheses 1984; 14:387-400. [PMID: 6387403 DOI: 10.1016/0306-9877(84)90145-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Two contrasting patients are described, one with pseudo-Bartter's syndrome induced by frusemide abuse and the other a case of hyporeninaemic hypoaldosteronism. The clinical and biochemical features of these two conditions are the opposite of each other and, in the first patient, the effects of frusemide were antagonised by treatment with indomethacin while in the second frusemide itself corrected the syndrome. The decreased pressor sensitivity to infused angiotensin II seen in the patient with pseudo-Bartter's syndrome was corrected with indomethacin and the enhanced pressor sensitivity seen in hyporeninaemic hypoaldosteronism was reversed with frusemide. Frusemide, an agent which blocks chloride transport at the ascending limb of Henle's loop, was respectively thus the cause and the cure of these conditions. On the basis of this the suggestion is made that Bartter's syndrome and hyporeninaemic hypoaldosteronism represent respectively an excess and a deficiency of a circulating factor similar to frusemide capable of blocking renal tubular chloride transport.
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31
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Adrogué HJ, Eknoyan G, Suki WK. Diabetic ketoacidosis: role of the kidney in the acid-base homeostasis re-evaluated. Kidney Int 1984; 25:591-8. [PMID: 6434787 DOI: 10.1038/ki.1984.62] [Citation(s) in RCA: 87] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abstract
A wide variety of pharmacologic agents have been implicated in a number of electrolyte disorders. The present review focuses on abnormalities of sodium, potassium, calcium, magnesium, and phosphate. Several mechanisms are involved in the pathogenesis of these disorders. These involve stimulation and modulation of other hormones (e.g., antidiuretic hormone, renin-angiotensin system, parathyroid hormone), damage to renal tubules, and, in some cases, a combination of factors. Recognition of these abnormalities is important because their presence may be life threatening or may aggravate the side effects of the drug itself.
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Drury PL, Bodansky HJ, Oddie CJ, Cudworth AG, Edwards CR. Increased plasma renin activity in type 1 diabetes with microvascular disease. Clin Endocrinol (Oxf) 1982; 16:453-61. [PMID: 7044618 DOI: 10.1111/j.1365-2265.1982.tb02759.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Plasma renin activity was measured in thirty-one subjects with Type 1 diabetes and proliferative retinopathy, and in seventeen matched diabetic subjects without evidence of any complications of their disease. The two groups were comparable for age, sex, smoking habits and duration of diabetes. Systolic and diastolic blood pressures were significantly higher in the patients with retinopathy (P less than 0.025 and P-0.05 respectively) and HbA1 was greater (P less tha 0.005) than in the patients without complications. Plasma renin activity, both lying and standing, was higher in the patients with retinopathy than in the uncomplicated group (P less than 0.05 for each). There were no correlations between plasma renin activity and mean blood pressure, HbA1 or fasting blood glucose. These findings raise the possibility that the renin-angiotensin system might be implicated in the pathogenesis of diabetic microvascular.
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Rosenstock J, Loizou SA, Brajkovich IE, Mashiter K, Joplin GF. Effect of acute hyperglycaemia on plasma potassium and aldosterone levels in type 2 (non-insulin-dependent) diabetes. Diabetologia 1982; 22:184-7. [PMID: 7042430 DOI: 10.1007/bf00283750] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Potassium homeostasis during a 50-g oral glucose tolerance test was studied in 14 newly diagnosed, untreated Type 2 (non-insulin-dependent) diabetics. They showed a rise in plasma potassium from a mean +/- SEM basal of 3.9 +/- 0.1 to 4.4 +/- 0.1 mmol/l at 60 min and to 4.6 +/- 0.1 mmol/l at 90 min (p less than 0.01), whereas no change was seen in a group of 14 normal subjects. A possible role of mineralocorticoids was sought by measuring simultaneous serum aldosterone and deoxycorticosterone levels. Aldosterone was reduced after the glucose load in all subjects studied, falling to 73% of basal at 60 min in diabetics (p less than 0.01), and to 61% of basal at 90 min in normal subjects (p less than 0.001). Serum deoxycorticosterone showed a similar pattern. Thus it is unlikely that the rise in plasma potassium seen in the diabetic patients was due to abnormal levels of mineralocorticoids. Since the diabetic subjects were found to have an intact insulin response to the glucose load, it is suggested that resistance to insulin-stimulated potassium uptake into cells might be involved in the pathogenesis of the paradoxical hyperkalaemia induced by acute hyperglycaemia.
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Abstract
In this review, the distal nephron is considered to be that portion of the renal tubule commencing with the thick ascending limb of the loop of Henle and ending with the papillary collecting duct. The collecting duct, including its subdivisions in the cortex and medulla, originates from a different embryologic anlage than more proximal nephron segments, which may explain its morphologic and functional dissimilarities from the thick ascending limb and the distal convoluted tubule. This review summarizes selected aspects of the physiology of the distal nephron, with particular emphasis on the physiology of distal nephron transport of sodium, potassium, chloride and hydrogen ion. The pathophysiologic features of the following disorders of distal nephron function are reviewed: (1) pseudohypoaldosteronism, a heterogenous group of disorders in which the signs and symptoms are suggestive of aldosterone deficiency, but in which aldosterone levels are supernormal and administration of exogenous mineralocorticoid is not ameliorative; (2) pseudohyperaldosteronism (Liddle syndrome), a familial disorder in which the clinical manifestations closely resemble those resulting from an aldosterone-producing adenoma of the adrenal gland (primary aldosteronism), but in which the measured rate of aldosterone secretion and excretion is greatly subnormal; (3) Bartter syndrome and related syndromes of renal potassium wasting; (4) type 1 renal tubular acidosis (classic, distal); (5) type 4 renal tubular acidosis (hyperkalemic). Reference citations are generally to articles reporting recent advances in these areas and to review articles that contain comprehensive bibliographies.
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Sowers JR, Tuck ML. Hypertension associated with diabetes mellitus, hypercalcaemic disorders, acromegaly and thyroid disease. CLINICS IN ENDOCRINOLOGY AND METABOLISM 1981; 10:631-56. [PMID: 7047021 DOI: 10.1016/s0300-595x(81)80015-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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37
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Nicholls MG, Espiner EA, Ikram H, Maslowski AH. Hyponatraemia in congestive heart failure during treatment with captopril. BRITISH MEDICAL JOURNAL 1980; 281:909. [PMID: 7000281 PMCID: PMC1714174 DOI: 10.1136/bmj.281.6245.909] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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