Comparison of methods for preservation of renal function during ischemic renal surgery

8-Aminoguanine Induces Diuresis, Natriuresis, and Glucosuria by Inhibiting Purine Nucleoside Phosphorylase and Reduces Potassium Excretion by Inhibiting Rac1

Background 8-Aminoguanosine and 8-aminoguanine are K⁺-sparing natriuretics that increase glucose excretion. Most effects of 8-aminoguanosine are due to its metabolism to 8-aminoguanine. However, the mechanism by which 8-aminoguanine affects renal function is unknown and is the focus of this investigation. Methods and Results Because 8-aminoguanine has structural similarities with inhibitors of the epithelial sodium channel (ENaC), Na⁺/H⁺ exchangers, and adenosine A₁ receptors, we examined the effects of 8-aminoguanine on EN aC activity in mouse collecting duct cells, on intracellular pH of human proximal tubular epithelial cells, on responses to a selective A₁-receptor agonist in vivo, and on renal excretory function in A₁-receptor knockout rats. These experiments showed that 8-aminoguanine did not block EN aC, Na⁺/H⁺ exchangers, or A₁ receptors. Because Rac1 enhances activity of mineralocorticoid receptors and some guanosine analogues inhibit Rac1, we examined the effects of 8-aminoguanine on Rac1 activity in mouse collecting duct cells. Rac1 activity was significantly inhibited by 8-aminoguanine. Because in vitro 8-aminoguanine is a purine nucleoside phosphorylase ( PNP ase) inhibitor, we examined the effects of a natriuretic dose of 8-aminoguanine on urinary excretion of PNP ase substrates and products. 8-Aminoguanine increased and decreased, respectively, urinary excretion of PNP ase substrates and products. Next we compared in rats the renal effects of intravenous doses of 9-deazaguanine ( PNP ase inhibitor) versus 8-aminoguanine. 8-Aminoguanine and 9-deazaguanine induced similar increases in urinary Na⁺ and glucose excretion, yet only 8-aminoguanine reduced K⁺ excretion. Nsc23766 (Rac1 inhibitor) mimicked the effects of 8-aminoguanine on K⁺ excretion. Conclusions 8-Aminoguanine increases Na⁺ and glucose excretion by blocking PNP ase and decreases K⁺ excretion by inhibiting Rac1.

The guanosine-adenosine interaction exists in vivo

In cultured renal cells and isolated perfused kidneys, extracellular guanosine augments extracellular adenosine and inosine (the major renal metabolite of adenosine) levels by altering the extracellular disposition of these purines. The present study addressed whether this "guanosine-adenosine mechanism" exists in vivo. In rats (n = 15), intravenous infusions of adenosine (1 µmol/kg per minute) decreased mean arterial blood pressure (MABP) from 114 ± 4 to 83 ± 5 mm Hg, heart rate (HR) from 368 ± 11 to 323 ± 9 beats/min), and renal blood flow (RBF) from 6.2 ± 0.5 to 5.3 ± 0.6 ml/min). In rats (n = 15) pretreated with intravenous guanosine (10 µmol/kg per minute), intravenous adenosine (1 µmol/kg per minute) decreased MABP (from 109 ± 4 to 58 ± 5 mm Hg), HR (from 401 ± 10 to 264 ± 20 beats/min), and RBF (from 6.2 ± 0.7 to 1.7 ± 0.3). Two-factor analysis of variance (2F-ANOVA) revealed a significant interaction (P < 0.0001) between guanosine and adenosine for MABP, HR, and RBF. In control rats, the urinary excretion rate of endogenous inosine was 211 ± 103 ng/30 minutes (n = 9); however, in rats treated with intravenous guanosine (10 µmol/kg per minute), the excretion rate of inosine was 1995 ± 300 ng/30 minutes (n = 12; P < 0.0001 versus controls). Because adenosine inhibits inflammatory cytokine production, we also examined the effects of intravenous guanosine on endotoxemia-induced increases in tumor necrosis factor-α (TNF-α). In control rats (n = 7), lipopolysaccharide (LPS; Escherichia coli 026:B6 endotoxin; 30 mg/kg) increased plasma TNF-α from 164 ± 56 to 4082 ± 730 pg/ml, whereas in rats pretreated with intravenous guanosine (10 µmol/kg per minute; n = 6), LPS increased plasma TNF-α from 121 ± 45 to 1821 ± 413 pg/ml (2F-ANOVA interaction effect, P = 0.0022). We conclude that the guanosine-adenosine mechanism exists in vivo and that guanosine may be a useful therapeutic for reducing inflammation.

Guanosine regulates adenosine levels in the kidney

In cell culture, extracellular guanosine increases extracellular adenosine by attenuating the disposition of extracellular adenosine (American Journal of Physiology – Cell Physiology 304: C406–C421, 2013). The goal of this investigation was to determine whether this “guanosine–adenosine mechanism” is operative in an intact organ. Twenty‐seven isolated, perfused mouse kidneys were subjected to metabolic poisons (iodoacetate plus 2,4‐dinitrophenol) to cause energy depletion and thereby stimulate renal adenosine production. Adenosine levels in the renal venous perfusate increased from a baseline of 36 ± 8 to 499 ± 96, 258 ± 50, and 71 ± 13 nmol/L at 15, 30, and 60 min, respectively, after administering metabolic poisons (% of basal; 1366 ± 229, 715 ± 128, and 206 ± 33, respectively). Changes in renal venous levels of guanosine closely mirrored the time course of changes in adenosine: baseline of 15 ± 2 to 157 ± 13, 121 ± 8, and 50 ± 5 nmol/L at 15, 30, and 60 min, respectively (% of basal; 1132 ± 104, 871 ± 59, and 400 ± 51, respectively). Freeze‐clamp experiments in 12 kidneys confirmed that metabolic poisons increased kidney tissue levels of adenosine and guanosine. In eight additional kidneys, we examined the ability of guanosine to reduce the renal clearance of exogenous adenosine; and these experiments revealed that guanosine significantly decreased the renal extraction of adenosine. Because guanosine is metabolized by purine nucleoside phosphorylase (PNPase), in another set of 16 kidneys we examined the effects of 8‐aminoguanine (PNPase inhibitor) on renal venous levels of adenosine and inosine (adenosine metabolite). Kidneys treated with 8‐aminoguanine showed a more robust increase in both adenosine and inosine in response to metabolic poisons. We conclude that in the intact kidney, guanosine regulates adenosine levels.

In cell culture, extracellular guanosine increases extracellular adenosine by attenuating the disposition of extracellular adenosine (American Journal of Physiology – Cell Physiology 304: C406–C421, 2013). The goal of this study was to determine whether the “guanosine–adenosine mechanism” is operative in an intact organ. In isolated, perfused mouse kidneys, inhibition of energy production induced changes in renal venous levels of guanosine that closely mirrored the time course of changes in adenosine, and freeze‐clamp experiments confirmed that metabolic poisons similarly increased kidney tissue levels of adenosine and guanosine. Moreover, exogenous guanosine significantly decreased the renal extraction of exogenous adenosine, and inhibition of purine nucleoside phosphorylase (metabolizes guanosine) augmented the effects of energy depletion on renal levels of both guanosine and adenosine. We conclude that in the intact kidney, guanosine regulates adenosine levels.

Comparative study between trimetazidine and ice slush hypothermia in protection against renal ischemia/reperfusion injury in a porcine model

PURPOSE

The aim of the study was to compare the effects of renal ice slush hypothermia and the use of trimetazidine in the protection against ischemia/reperfusion (I/R) injury.

MATERIALS AND METHODS

Fifteen farm pigs were submitted to left kidney ischemia and right nephrectomy during the same procedure. Animals were divided into three groups. Group 1 was submitted to warm ischemia; Group 2 was submitted to cold ischemia with ice slush; and Group 3 received trimetazidine 20 mg one day and 4 hours before surgery. Ischemia time was 120 minutes in all three groups. Serum creatinine (SCr) and plasma iohexol clearance (CLioh) were measured before surgery and on postoperative days (PODs) 1,3,7, and 14. Semi-quantitative analyses of histological alterations were performed by a pathologist. A p value of < 0.05 was considered significant.

RESULTS

All groups showed elevation of serum creatinine in the first week. Serum creatinine was higher in Group 3 in the first and third postoperative days (Mean Cr: 5.5 and 8.1 respectively). Group 2 showed a lower increase in creatinine and a lower decrease in iohexol clearance than the others. Renal function stabilized in the fourteenth POD in all three groups. Analyses of histological alterations did not reach statistical significance between groups.

CONCLUSION

Trimetazidine did not show protection against renal I/R injury in comparison to warm ischemia or hypothermia in a porcine model submitted to 120 minutes of renal ischemia.

Importance and limits of ischemia in renal partial surgery: experimental and clinical research

Introduction. The objective is to determine the clinical and experimental evidences of the renal responses to warm and cold ischemia, kidney tolerability, and available practical techniques of protecting the kidney during nephron-sparing surgery. Materials and methods. Review of the English and non-English literature using MEDLINE, MD Consult, and urology textbooks. Results and discussion. There are three main mechanisms of ischemic renal injury, including persistent vasoconstriction with an abnormal endothelial cell compensatory response, tubular obstruction with backflow of urine, and reperfusion injury. Controversy persists on the maximal kidney tolerability to warm ischemia (WI), which can be influenced by surgical technique, patient age, presence of collateral vascularization, indemnity of the arterial bed, and so forth. Conclusions. When WI time is expected to exceed from 20 to 30 minutes, especially in patients whose baseline medical characteristics put them at potentially higher, though unproven, risks of ischemic damage, local renal hypothermia should be used.

The laparoscopic cooling sheath: novel device for hypothermic preservation of kidney during temporary renal artery occlusion

Hypothermia is commonly used to prevent ischemic renal damage during complex nephron-sparing surgical procedures requiring temporary renal artery occlusion. We developed a novel Cooling Sheath device, which is compatible with laparoscopy, to protect the kidney hypothermically during 60 minutes of temporary arterial occlusion in a laparoscopic swine model. Comparison of temperature curves and histology to control groups undergoing open slush surface cooling and laparoscopic warm ischemia for similar time periods was performed. Optimal hypothermic temperatures were reached rapidly and maintained with the use of the Cooling Sheath. Ischemic damage, present in all kidneys subjected to warm ischemia, was not found on histopathologic examination of the cooled kidneys. This new device provides hypothermic protection of the kidney during ischemia. The use of the Cooling Sheath combined with temporary arterial occlusion will allow more complex nephron-sparing renal surgery to be performed using laparoscopy.