Role of Urinary Arginine Vasopressin in the Sodium Excretion in Patients With Chronic Renal Failure

Comparison of the effects of tolvaptan and furosemide on renal water and sodium excretion in patients with heart failure and advanced chronic kidney disease: a subanalysis of the K-STAR study

BACKGROUND

Tolvaptan (TLV) is known to increase electrolyte-free water clearance. However, TLV actions on renal electrolytes including urine sodium (uNa) excretion and its consequences are less well understood. This subanalysis investigated the effect of add-on TLV compared to increased furosemide (FUR) on both electrolyte-free water and electrolyte clearance in patients with congestive heart failure (CHF) complicated by advanced chronic kidney disease (CKD).

METHODS

The Kanagawa Aquaresis Investigators Trial of TLV on HF Patients with Renal Impairment (K-STAR) was a multicenter, open-labeled, randomized, and controlled prospective clinical study. Eighty-one Japanese patients with CHF and residual signs of congestion despite oral FUR treatment (≥ 40 mg/day) were recruited and randomly assigned to a 7-day add-on treatment with either ≤ 40 mg/day FUR or ≤ 15 mg/day TLV. Electrolyte-free water clearance, electrolyte osmolar clearance and electrolyte excretion were compared between the two groups before and after therapy.

RESULTS

The change (Δ) in electrolyte-free water clearance was significantly higher in the add-on TLV group than in the add-on FUR group. However, Δelectrolyte osmolar clearance was also higher in the add-on TLV group than in the increased FUR group. This was primarily because ΔuNa excretion was significantly higher in the add-on TLV group than in the increased FUR group, since Δurine potassium excretion was significantly lower in the add-on TLV group than in the increased FUR group.

CONCLUSIONS

Add-on TLV may increase both renal water and Na excretion in CHF patients with advanced CKD to a greater degree than increased FUR.

Early, but not late therapy with a vasopressin V1a-antagonist ameliorates the development of renal damage after 5/6 nephrectomy

Introduction. Vasopressin, mainly through the V1a-receptor, is thought to be a major player in the maintenance of hyperfiltration. Its inhibition could therefore lead to a decrease in progression of chronic renal failure.To this end, the effect of the vasopressin V1a-receptor-selective antagonist, YM218, was studied on proteinuria and focal glomerulosclerosis in early and late intervention after 5/6 nephrectomy in rats, and compared with an angiotensin-converting enzyme inhibitor (ACE-I).

Materials and methods. After 5/6 nephrectomy, early intervention was performed between week 2 and 10 thereafter with the V1a-receptor-selective antagonist (VRA, 10 mg/kg/day, n=10), enalapril (ACE-I, 10 mg/kg/day, n=9), or vehicle (n=8). Late intervention was performed in another group between week 6 and 12 with VRA (10 mg/kg/day, n=7), lisinopril (ACE-I, 5 mg/kg/day, n=7), or vehicle (n=7).

Results. In early intervention, proteinuria and focal glomerulosclerosis were significantly decreased by VRA compared to vehicle (44 7% and 59+8% respectively). ACE-I significantly decreased proteinuria (67 7%) and a trend towards a decrease in focal glomerulosclerosis was observed (30 18%). In late intervention, VRA did not decrease proteinuria and focal glomerulosclerosis compared to vehicle (21 20% and 0%, respectively),ACE-I significantly lowered proteinuria (92 2%) and a focal glomerulosclerosis (69+1%) lowering trend was observed.

Conclusion. These results indicate that VRA may protect against early progression of renal injury after 5/6 nephrectomy, whereas its effectiveness seems limited in established renal damage.

Vasopressin: a novel target for the prevention and retardation of kidney disease?

After several decades during which little attention was paid to vasopressin and/or urine concentration in clinical practice, interest in vasopressin has renewed with the availability of new, potent, orally active vasopressin-receptor antagonists--the vaptans--and with the results of epidemiological studies evaluating copeptin (a surrogate marker of vasopressin) in large population-based cohorts. Several experimental studies in rats and mice had previously shown that vasopressin, acting via vasopressin V2 antidiuretic receptors, contributes to the progression of chronic kidney disease; in particular, to autosomal dominant polycystic kidney disease. New epidemiological studies now suggest a role for vasopressin in the pathogenesis of diabetes mellitus and metabolic disorders via activation of hepatic V1a and/or pancreatic islet V1b receptors. The first part of this Review describes the adverse effects of vasopressin, as revealed by clinical and experimental studies in kidney diseases, hypertension, diabetes and the metabolic syndrome. The second part provides insights into vasopressin physiology and pathophysiology that may be relevant to the understanding of these adverse effects and that are linked to the excretion of concentrated nitrogen wastes and associated hyperfiltration. Collectively, the studies reviewed here suggest that more attention should be given to the vasopressin-thirst-urine concentration axis in clinical investigations and in patient care. Whether selective blockade of the different vasopressin receptors may provide therapeutic benefits beyond their present indication in hyponatraemia requires new clinical trials.

Vasopressin V1a and V1b Receptors: From Molecules to Physiological Systems

The neurohypophysial hormone arginine vasopressin (AVP) is essential for a wide range of physiological functions, including water reabsorption, cardiovascular homeostasis, hormone secretion, and social behavior. These and other actions of AVP are mediated by at least three distinct receptor subtypes: V1a, V1b, and V2. Although the antidiuretic action of AVP and V2 receptor in renal distal tubules and collecting ducts is relatively well understood, recent years have seen an increasing understanding of the physiological roles of V1a and V1b receptors. The V1a receptor is originally found in the vascular smooth muscle and the V1b receptor in the anterior pituitary. Deletion of V1a or V1b receptor genes in mice revealed that the contributions of these receptors extend far beyond cardiovascular or hormone-secreting functions. Together with extensively developed pharmacological tools, genetically altered rodent models have advanced the understanding of a variety of AVP systems. Our report reviews the findings in this important field by covering a wide range of research, from the molecular physiology of V1a and V1b receptors to studies on whole animals, including gene knockout/knockdown studies.

Low pH stimulates vasopressin V2 receptor promoter activity and enhances downregulation induced by V1a receptor stimulation

Arginine vasopressin (AVP) plays a key role in the urine concentration mechanism via the vasopressin V2 receptor (V2R) and aquaporin 2 (AQP2) in the kidney. It is well known that V2R is localized on the basolateral side and the V1a receptor (V1aR) is distributed on the luminal side of the collecting ducts. Previously, we reported an increase of V1aR mRNA and a decrease of V2R mRNA in the collecting ducts under chronic metabolic acidosis. However, the regulatory mechanism of V2R in acidic conditions has not yet been determined. In the present study, we investigated the effect of changes in pH on V2R promoter activity, using the LLC-PK(1) cell line stably expressing rat V1aR (LLC-PK(1)/rV1aR). The rV2R promoter activity was significantly increased at 12 h after the incubation in low-pH conditions, which was sustained for 24 h. mRNA and protein expressions of V2R were also increased in low-pH conditions. V1aR stimulation suppressed rV2R promoter activity in a pH-dependent manner. PKA and JNK inhibitors suppressed rV2R promoter activity in both neutral and low-pH conditions without FBS. However, a JNK inhibitor prevented the increase of V2R promoter activity only in low-pH conditions in the presence of FBS. In summary, V2R expression is increased at transcriptional, mRNA, and protein levels in LLC-PK(1)/rV1aR cells under low-pH conditions. Acidic condition-induced V2R enhancement was suppressed by V1aR stimulation, suggesting the crucial role of V1aR in water and electrolyte homeostasis in acidosis.

Downregulation of vasopressin V2 receptor promoter activity via V1a receptor pathway

Vasopressin V(1a) and V(2) receptors (V(1a)R and V(2)R, respectively) distribute in the collecting duct of the kidney. Although the function of V(2)R mediating the antidiuretic effect of AVP has been investigated in detail, the role of V(1a)R in the collecting ducts has not been elucidated. In the present study, we have investigated the role of the V(1a)R pathway in V(2)R promoter activity. We cloned the 5'-flanking region of rat V(2)R (rV(2)R) and investigated rV(2)R promoter activity in the LLC-PK(1) cell line transfected to express rat V(1a)R (rV(1a)R) dominantly (LLC-PK(1)/rV(1a)R). AVP induced a transient increase, followed by a sustained decrease, of rV(2)R promoter activity in these cells. This AVP-induced decrease of rV(2)R promoter activity was inhibited by V(1a)R, but not V(2)R, antagonist. PMA mimicked this decrease of rV(2)R promoter activity. On the contrary, 8-(4-chlorophenylthio)-cAMP increased rV(2)R promoter activity. These PMA- and 8-(4-chlorophenylthio)-cAMP-induced effects were not observed on the deletion segment of the 5'-flanking region lacking CAAT and SP1 sites. In conclusion, 1) expression of the V(2)R is downregulated via the V(1a)R pathway in LLC-PK(1)/rV(1a)R cells, and 2) expression of the V(2)R is downregulated by the PMA-induced PKC pathway and upregulated by the cAMP-PKA pathway. These opposite effects of PKC and PKA appear to be regulated by the same promoter region of CAAT and SP1.

Arginine vasopressin stimulates H+-ATPase in MDCK cells via V1 (cell Ca2+) and V2 (cAMP) receptors

The effect of arginine vasopressin (AVP) and/or atrial natriuretic peptide (ANP) on the regulation of intracellular pH (pHi) via H+-ATPase and of cytosolic calcium ([Ca2+]i) was investigated in Madin-Darby canine kidney (MDCK) cells by the fluorescent probes BCECF-AM and fluo-4-AM, respectively. The pHi recovery rate was examined after intracellular acidification following an NH4Cl pulse, in the presence of zero Na+ plus Schering 28080 (a specific inhibitor of H+-K+-ATPase). AVP (10-12-10-6 M) increased the rate of pHi recovery and [Ca2+]i in a dose-dependent manner. V1- or V2-receptor antagonists impaired the effect of AVP on both processes, and DDAVP (10-12-10-6 M; a V2-selective agonist) caused a dose-dependent stimulation of them. [Ca2+]i or cAMP (as increased by 10-5 M thapsigargin or 8-BrcAMP, respectively) alone had no effect on H+-ATPase, but their synergic action was necessary to stimulate H+-ATPase. In agreement with these findings, ANP (10-6 M) or dimethyl-BAPTA-AM (5 x 10-5 M), impairing the increase of [Ca2+]i in response to AVP, blocks the stimulatory effect of AVP on H+-ATPase.

Peritubular AVP regulates bicarbonate reabsorption in cortical distal tubule via V(1) and V(2) receptors

Peritubular arginine vasopressin (AVP) regulates bicarbonate reabsorption in the cortical distal tubule via V(1) and V(2) receptors. The dose-dependent effects of peritubular AVP on net bicarbonate reabsorption (J(HCO)) were evaluated by stationary microperfusion of in vivo early (ED; distal convoluted tubule) and late distal (LD; connecting tubule and initial collecting duct) segments of rat kidney, using double-barreled H(+)-sensitive, ion-exchange resin/reference (1 M KCl) microelectrodes. AVP (10(-11) M) perfused into peritubular capillaries increased J(HCO), compared with basal levels during intact capillary perfusion with blood, in ED and LD segments. AVP (10(-9) M) also increased J(HCO) in both segments, but the effect of AVP (10(-11) M) was significantly higher. A specificV(1)-receptor antagonist alone or with AVP (10(-11) or 10(-9) M) reduced J(HCO) below basal levels. A specific V(2)-receptor antagonist alone or plus AVP (10(-11) M) did not affect J(HCO) but increased AVP (10(-9) M)-mediated stimulation. 8-Bromoadenosine 3',5'-cyclic monophosphate alone reduced J(HCO) below basal levels and also reduced AVP (10(-11) M)-mediated stimulation. (Deamino-Cys(1), D-Arg(8)) vasopressin (a V(2)-selective agonist) also reduced J(HCO) below basal levels. These results show that peritubular AVP stimulates J(HCO) in ED and LD segments via basolateral V(1) receptors and that basolateral V(2) receptors have a dose-dependent inhibitory effect mediated by cAMP. The data also indicate that endogenous AVP stimulates distal J(HCO) via basolateral V(1) receptors.

Effect of arginine vasopressin and ANP on intracellular pH and cytosolic free [Ca2+] regulation in MDCK cells

BACKGROUND

The effects of arginine vasopressin (AVP) on intracellular pH (pHi) are not clearly defined, and may vary with cell membrane surface and the hormonal doses being studied. Since cytosolic free calcium concentration ([Ca2+]i) has an important effect on cellular H+ extrusion and it was shown that AVP increases [Ca2+]i while atrial natriuretic peptide (ANP) reduces it, there may be some interaction between AVP and ANP during the regulation of pHi.

METHODS

The effects of AVP and/or ANP on pHi and [Ca2+]i were investigated in Madin-Darby canine kidney (MDCK) cells by the fluorescent probes BCECF-AM and Fluo 4-AM, respectively. The pHi recovery rate was examined in the first two minutes following the acidification of pHi with a NH4Cl pulse.

RESULTS

AVP (10(-12) or 10(-9) mol/L) stimulated the rate of the Na+-dependent pHi recovery, but AVP (10(-6) mol/L) impaired it. At the apical membrane surface, specific V1 or V2 receptor antagonists did not alter the effects of AVP. At the basolateral membrane surface, the V1 antagonist returned both the stimulatory and inhibitory effects of AVP to control levels, and the V2 antagonist converted the inhibitory effect of AVP to a stimulatory effect. ANP (10(-6) mol/L) or dimethyl-BAPTA-AM (50 micromol/L) impaired both the stimulatory and inhibitory effects of AVP. AVP increased [Ca2+]i in a dose-dependent manner. ANP or dimethyl-BAPTA-AM decreased [Ca2+]i, and the subsequent addition of AVP caused only a partial recovery of [Ca2+]i.

CONCLUSIONS

The results are compatible with stimulation of the Na+/H+ exchanger by increases of [Ca2+]i in the lower range (at 10(-12) or 10(-9) mol/L AVP, via basolateral V1 receptors) and inhibition at high [Ca2+]i levels (at 10(-6) mol/L AVP, via basolateral V1 and V2 receptors). ANP, by impairing the path causing the increase in [Ca2+]i, blocks both the stimulatory and inhibitory effects of AVP on Na+-dependent pHi recovery.

V(1) receptors in luminal action of vasopressin on distal K(+) secretion

Luminal perfusion with collected proximal fluid increases distal K(+) secretion compared with artificial solutions. Arginine vasopressin (AVP), present in luminal fluid, might be responsible for this observation. K(+) secretion rate (J(K)) was measured by K(+)-sensitive microelectrodes during paired luminal stationary microperfusion with control and AVP-containing 0.5 mM K(+) solutions. J(K) was 1.34 +/- 0.35 (n = 24 tubules) nmol x cm(-2) x s(-1) during perfusion with 10(-9) M AVP, against 0.90+/-0.12 nmol x cm(-2) x s(-1) (n = 21) in control (P<0.02). With 10(-9) M AVP+10(-6) M beta-mercapto-beta-beta-cyclopenta-methylenepropionyl(1), O-Me-Tyr(2)-Arg(8) vasopressin (MCMV), a specific peptide V(1)-receptor antagonist, J(K) was 0.36+/-0.067 against 0.77+/-0.10 (control; n = 9) nmol x cm(-2) x s(-1) (P<0.01). With 10(-6) M MCMV alone, J(K) was 0.37+/-0.04 against a control of 0.62+/-0.06 (n = 19) nmol. cm(-2). s(-1) (P<0.01). A peptide V(2) antagonist had no such effect. In Brattleboro rats, which do not produce endogenous AVP, MCMV had no effect when given alone, although AVP still stimulated J(K). In conclusion, luminal AVP stimulates distal J(K) significantly. The V(1) antagonist MCMV inhibits the effect of AVP but also reduces J(K) when given alone. This suggests that AVP acts luminally via V(1) receptors but also that there appears to be a background effect of endogenous AVP blocked by the antagonist.