Glomerular hemodynamics before and after release of 24-hour bilateral ureteral obstruction

Acute Kidney Injury: Medical Causes and Pathogenesis

Acute kidney injury (AKI) is a common clinical syndrome characterized by a sudden decline in or loss of kidney function. AKI is not only associated with substantial morbidity and mortality but also with increased risk of chronic kidney disease (CKD). AKI is classically defined and staged based on serum creatinine concentration and urine output rates. The etiology of AKI is conceptually classified into three general categories: prerenal, intrarenal, and postrenal. Although this classification may be useful for establishing a differential diagnosis, AKI has mostly multifactorial, and pathophysiologic features that can be divided into different categories. Acute tubular necrosis, caused by either ischemia or nephrotoxicity, is common in the setting of AKI. The timely and accurate identification of AKI and a better understanding of the pathophysiological mechanisms that cause kidney dysfunction are essential. In this review, we consider various medical causes of AKI and summarize the most recent updates in the pathogenesis of AKI.

Low-Flow Acute Kidney Injury: The Pathophysiology of Prerenal Azotemia, Abdominal Compartment Syndrome, and Obstructive Uropathy

AKI is a syndrome, not a disease. It results from many different primary and/or secondary etiologies and is often multifactorial, especially in the hospitalized patient. This review discusses the pathophysiology of three etiologies that cause AKI, those being kidney hypoperfusion, abdominal compartment syndrome, and urinary tract obstruction. The pathophysiology of these three causes of AKI differs but is overlapping. They all lead to a low urine flow rate and low urine sodium initially. In all three cases, with early recognition and correction of the underlying process, the resulting functional AKI can be rapidly reversed. However, with continued duration and/or increased severity, cell injury occurs within the kidney, resulting in structural AKI and a longer and more severe disease state with increased morbidity and mortality. This is why early recognition and reversal are critical.

Validation of robotic-assisted ureteroplasty with buccal mucosa graft for stricture at the proximal and middle ureters: the first comparative study

Although ureteroplasty with buccal mucosa graft for long-segmental ureteral stenosis has been developed long ago, evidence was still restricted to case series in published literature. This study aims to validate ureteroplasty with buccal mucosa graft (BMG) in long-segment stricture at the proximal and middle ureters under designed comparative methods. From April 2015 to January 2019, we performed robotic-assisted ureteroplasty with BMG with a two-phase design and compared ureteroplasty and BMG (phase 2 surgery) with endoscopic stenting (phase 1 surgery). Paired data of effective renal plasma flow (ERPF), glomerular filtration rate (GFR), hydronephrosis grade, and physical and psychological domains of the World Health Organization Quality of Life (WHOQOL)-BREF were compared. A total of 29 patients were enrolled, and only three (10%) patients had hydronephrosis resolution after treatment with endoscopic stenting (p = 0.250 to baseline). Compared to endoscopic ureteral stent, Hedges' g of ureteroplasty with BMG was 0.56 (95% CI 0.43-0.69), 0.63 (95% CI 0.46-0.80), 0.80 (95% CI 0.56-1.04), and 1.06 (95% CI 0.69-1.43) in EGFR, GFR, physical domain of WHOQOL-BREF, and psychological domain of WHOQOL-BREF, respectively (All significance; p < 0.001). After 12-month follow-ups, no recurrence of stricture was reported. In conclusion, Robotic-assisted ureteroplasty with BMG onlay is efficient in reconstruction of long-segment stricture of the proximal and middle ureters.

Acute Kidney Injury Caused by Obstructive Nephropathy

Acute kidney injury secondary to obstructive nephropathy is a frequent event that accounts for 5 to 10% of all acute kidney injury cases and has a great impact on the morbidity and mortality in those affected. The obstruction in the urinary tract has a profound impact on kidney function due to damage produced by ischemic and inflammatory factors that have been associated with intense fibrosis. This pathology is characterized by its effects on the management of fluids, electrolytes, and the acid-base mechanisms by the renal tubule; consequently, metabolic acidosis, hyperkalemia, uremia, and anuria are seen during acute kidney injury due to obstructive nephropathy, and after drainage, polyuria may occur. Acute urine retention is the typical presentation. The diagnosis consists of a complete medical history and should include changes in urinary voiding and urgency and enuresis, history of urinary tract infections, hematuria, renal lithiasis, prior urinary interventions, and constipation. Imaging studies included tomography or ultrasound in which hydronephrosis can be seen. Management includes, in addition to drainage of the obstructed urinary tract system, providing supportive treatment, correcting all the metabolic abnormalities, and initiating renal replacement therapy when required. Although its recovery is in most cases favorable, it seems to be an undervalued event in nephrology and urology. This is because it is mistakenly believed that the resolution and recovery of kidney function is complete once the urinary tract is unobstructed. It can have serious kidney sequelae. In this review, we report the epidemiology, incidence, pathophysiological mechanisms, diagnosis, and treatment of acute kidney injury due to obstructive nephropathy.

Melatonin therapy protects against renal injury before and after release of bilateral ureteral obstruction in rats

AIM

Blockage of the urinary tract is often connected with renal function impediment, including reductions in glomerular filtration rate (GFR) and the power to control sodium as well as water elimination through urination. Melatonin, known to be the primary product of the pineal gland, prevents renal damage caused by ischemic reperfusion. However, the effects of melatonin on urinary obstruction, as well as release of obstruction induced kidney injury are still largely unknown. The aim of present study was to investigate the effect of melatonin on mediating protection against renal injury triggered from either bilateral ureteral obstruction (BUO) or BUO release (BUO-R).

MAIN METHODS

Adult male Sprague-Dawley rats (n = 60) were clustered into six treatment groups: sham treated-1; BUO-non-treated (24 h BUO only); BUO + melatonin; sham treated-2; BUO-48hR (24 h of BUO and then release for 2 days); and BUO-48hR + melatonin. Kidney tissues, blood and urine samples were obtained for further assessment.

KEY FINDINGS

It was found that melatonin treatment remarkably promoted the recovery of the handling capacity of urinary excretion of water as well as sodium in BUO and BUO-48hR models. Melatonin treatment partially inhibited inflammatory cytokine expression and the downregulation of aquaporin (AQPs, AQP-1, -2 and -3) expression in these two models. Moreover, the cytoarchitecture of BUO rats exposed to melatonin was well preserved.

SIGNIFICANCE

Melatonin treatment potently prevents BUO or BUO-R induced renal injury, which may be partially attributed to restoring the expression of AQPs and inhibition of inflammatory response, as well as preserving renal ultrastructural integrity.

Potential Role of the Resident Mesenchymal Stem-Like Cells in Renal Fibrogenesis after Ureteral Obstruction

The mechanisms of renal fibrogenesis after ureteral obstruction remain unclear. We tried to primarily expand mesenchymal stem cells from renal tissues and then investigated their role in fibrogenesis after ureteral obstruction. Unilateral ureteral obstruction was induced by ligating the left ureteral duct of adult C57BL/6 mice. We collected the kidneys for experiments at 2, 7, and 14 days after operation. Histological analysis showed obviously fibrotic changes in the left kidney at 7 days and further increased at 14 days after ureteral obstruction. To expand mesenchymal stem cells, we minced the renal tissues into small explants (about 1 mm³) and cultured onto 10 cm dishes. Interestingly, the outgrowth of cells was observed significantly earlier from the explants of the obstructed left kidney than that of the unobstructed right kidney. These expanded cells showed the potency of adipogenic, osteogenic, and chondrogenic differentiations and positively expressed with CD44 and partly expressed with CD90, CD105, and CD106, but negatively expressed with CD34, CD45, and FSP1, suggesting the phenotype of mesenchymal stem-like cells (MSLCs). The mouse fibrosis RT² profiler PCR array showed that many genes were changed over 2-fold in the MSLCs expanded from both kidneys at 2, 7, and 14 days after operation. Interestingly, profibrotic genes were prevalently enhanced in the left kidney with ureteral obstruction. Histological analysis also showed obviously infiltration of inflammatory cells in the left kidney at 14 days after operation. Our data indicate the potential role of resident MSLCs in renal fibrogenesis after ureteral obstruction, but further experiments are required to understand the relevant mechanisms.

Mesenchymal Stromal Cells Prevent Renal Fibrosis in a Rat Model of Unilateral Ureteral Obstruction by Suppressing the Renin-Angiotensin System via HuR

We studied Mesenchymal Stromal Cells (MSC) effects in experimental Unilateral Ureteral Obstruction (UUO), a fibrogenic renal disease. Rats were divided in 5 groups: sham, UUO, MSC treated-UUO, ACEi treated-UUO, MSC+ACEi treated- UUO. Data were collected at 1, 7, 21 days. UUO induced monocyte renal infiltration, tubular cell apoptosis, tubular atrophy, interstitial fibrosis and overexpression of TGFβ, Renin mRNA (RENmRNA), increase of Renin, Angiotensin II (AII) and aldosterone serum levels. Both lisinopril (ACEi) and MSC treatment prevented monocyte infiltration, reduced tubular cell apoptosis, renal fibrosis and TGFβ expression. Combined therapy provided a further suppression of monocyte infiltration and tubular injury. Lisinopril alone caused a rebound activation of Renin-Angiotensin System (RAS), while MSC suppressed RENmRNA and Renin synthesis and induced a decrease of AII and aldosterone serum levels. Furthermore, in in-vitro and in-vivo experiments, MSC inhibit Human antigen R (HuR) trascription, an enhancer of RENmRNA stability by IL10 release. In conclusion, we demonstrate that in UUO MSC prevent fibrosis, by decreasing HuR-dependent RENmRNA stability. Our findings give a clue to understand the molecular mechanism through which MSC may prevent fibrosis in a wide and heterogeneous number of diseases that share RAS activation as common upstream pathogenic mechanism.

The risk factors and clinical significance of acute postoperative complications after unstented pediatric pyeloplasty: a single surgeon's experience

PURPOSE

To analyze the risk factors and clinical significance of postoperative complications after unstented pediatric pyeloplasty.

MATERIALS AND METHODS

We analyzed 285 kidney units (KUs) on which unstented pyeloplasty was performed between April 2002 and March 2010. Measures included preoperative factors, postoperative complications, change in postoperative differential renal function (DRF), and failure of pyeloplasty. Risk factors for acute complications requiring additional ureteral stenting and decreased DRF were analyzed.

RESULTS

During a median follow-up period of 67.0 months, an additional ureteral stenting was required in 28 KUs (9.8%) due to the development of acute postoperative complications after unstented pyeloplasty. The incidence of complications increased significantly as preoperative DRF increased. DRF of more than 60% was the only independent risk factor for acute complications. Postoperative decrease in DRF was observed in 58 KUs (22.4%) among 259 KUs analyzed. Pyeloplasty failure was observed in 10 KUs (3.5%). The development of acute complications was not a risk factor for a decrease in DRF or pyeloplasty failure.

CONCLUSIONS

Urinary diversion during pyeloplasty is not related to a decrease in DRF or pyeloplasty failure. However, in patients with a preoperative DRF of greater than 60%, diversion could be considered due to the high prevalence of complications.

Urinary tract obstruction induces transient accumulation of COX-2-derived prostanoids in kidney tissue

Inhibitors of cyclooxygenase (COX)-2 prevent suppression of aquaporin-2 and reduce polyuria in the acute phase after release of bilateral ureteral obstruction (BUO). We hypothesized that BUO leads to COX-2-mediated local accumulation of prostanoids in inner medulla (IM) tissue. To test this, rats were subjected to BUO and treated with selective COX-1 or COX-2 inhibitors. Tissue was examined at 2, 6, 12, and 24 h after BUO. COX-2 protein abundance increased in IM 12 and 24 h after onset of BUO but did not change in cortex. COX-1 did not change at any time points in any region. A full profile of all five primary prostanoids was obtained by mass spectrometric determination of PGE(2), PGF(2alpha), 6-keto-PGF(1alpha), PGD(2), and thromboxane (Tx) B(2) concentrations in kidney cortex/outer medulla and IM fractions. IM concentration of PGE(2), 6-keto-PGF(1alpha), and PGF(2alpha) was increased at 6 h BUO, and PGE(2) and PGF(2alpha) increased further at 12 h BUO. TxB(2) increased after 12 h BUO. 6-keto-PGF(1alpha) remained significantly increased after 24 h BUO. The COX-2 inhibitor parecoxib lowered IM PGE(2,) TxB(2), 6-keto-PGF(1alpha), and PGF(2alpha) below vehicle-treated BUO and sham rats at 6, 12 and, 24 h BUO. The COX-1 inhibitor SC-560 lowered PGE(2), PGF(2alpha), and PGD(2) in IM compared with untreated 12 h BUO, but levels remained significantly above sham. In cortex tissue, PGE(2) and 6-keto-PGF(1alpha) concentrations were elevated at 6 h only. In conclusion, COX-2 activity contributes to the transient increase in prostacyclin metabolite 6-keto-PGF(1alpha) and TxB(2) concentration in the kidney IM, and COX-2 is the predominant isoform that is responsible for accumulation of PGE(2) and PGF(2alpha) with minor, but significant, contributions from COX-1. PGD(2) synthesis is mediated exclusively by COX-1. In BUO, therapeutic interventions aimed at the COX-prostanoid pathway should target primarily COX-2.

Short-term regulation of organic anion transporters

Organic anion transporters (OATs), which belong to the superfamily SLC22A, are key determinants in the absorption, distribution, and excretion of a diverse array of environmental toxins, and clinically important drugs, and, therefore, are critical for the survival of mammalian species. Alteration in the function of these drug transporters plays important roles in intra- and inter-individual variability of the therapeutic efficacy and the toxicity of many drugs. As a result, the activity of OATs must be under tight regulation so as to carry out their normal functions. This review article highlights the recent advances from our laboratory as well as from others in delineating the short-term regulation of OATs. These advances provide important insights into strategies to maximize therapeutic efficacy in drug development.

Altered expression of rat renal cortical OAT1 and OAT3 in response to bilateral ureteral obstruction

BACKGROUND

Bilateral ureteral obstruction (BUO) is characterized by the development of hemodynamic and tubular lesions. However, little is known about the expression of organic anion renal transporters. The objective of this work was to study the renal excretion of p-aminohippurate (PAH) and the cortical renal expression of the organic anion transporter 1 (OAT1) and organic anion transporter 3 (OAT3) in BUO rats.

METHODS

Male Wistar rats underwent bilateral obstruction of the proximal ureters for 24 hours (BUO) or sham operation. After 24 hours of ureteral releasing, the following studies were performed: PAH renal excretion employing conventional clearance techniques and OAT1 and OAT3 abundance (homogenates, intracellular and basolateral plasma membrane fractions from renal cortex) using immunoblotting and immunocytochemical techniques (light microscopic and confocal immunofluorescence microscopic analysis).

RESULTS

BUO rats showed a lower renal excretion of PAH. In obstructed kidneys, immunoblotting revealed a significant decrease in the abundance of both OAT1 and OAT3 in basolateral plasma membranes from renal cortex. An increase of OAT1 expression was observed in homogenates and in intracellular membrane fractions in kidneys from BUO rats compared with sham-operated ones, indicating an internalization of this carrier. Immunocytochemical techniques confirmed these results. On the contrary, OAT3 expression was reduced both in homogenates and in intracellular membrane fractions in obstructed kidneys.

CONCLUSION

BUO was associated with down-regulation of OAT1 and OAT3 in basolateral plasma membranes from proximal tubule cells, thus these carriers may play important roles in the impaired organic anion excretion displayed in the obstructed kidney.

alpha-MSH prevents impairment in renal function and dysregulation of AQPs and Na-K-ATPase in rats with bilateral ureteral obstruction

The purpose of this study was to evaluate the effects of the anti-inflammatory hormone alpha-melanocyte-stimulating hormone (alpha-MSH) treatment on renal function and expression of aquaporins (AQPs) and Na-K-ATPase in the kidney in response to 24 h of bilateral ureteral obstruction (BUO) or release of BUO (BUO-R). In rats with 24-h BUO, immunoblotting revealed that downregulation of AQP2 and AQP3 was attenuated (AQP2: 38 +/- 5 vs. 13 +/- 4%; AQP3: 44 +/- 3 vs. 19 +/- 4% of sham levels; P < 0.05), whereas downregulation of Na-K-ATPase was prevented by alpha-MSH treatment (Na-K-ATPase: 94 +/- 7 vs. 35 +/- 5% of sham levels; P < 0.05). Immunocytochemistry confirmed the changes in AQP1 and Na-K-ATPase expression. Renal tubular cell apoptosis was confirmed in BUO kidneys, and alpha-MSH treatment virtually completely abolished apoptosis. Furthermore, we measured glomerular filtration rate (GFR) and effective renal plasma flow (ERPF), respectively. Forty-eight hours after BUO-R demonstrated that alpha-MSH treatment almost completely prevented the decrease in GFR (nontreated: 271 +/- 50; alpha-MSH: 706 +/- 85; sham: 841 +/- 105 microl x min(-1).100 g body wt(-1), P < 0.05) and ERPF (nontreated: 1,139 +/- 217; alpha-MSH: 2,598 +/- 129; sham: 2,633 +/- 457 microl x min(-1).100 g body wt(-1), P < 0.05). alpha-MSH treatment also partly prevented the downregulation of AQP1 and Na-K-ATPase expression in rats after BUO-R for 48 h. In conclusion, alpha-MSH treatment significantly prevents impairment in renal function and also prevents downregulation of AQP2, AQP3, and Na-K-ATPase during BUO or AQP1 and Na-K-ATPase after BUO-R, demonstrating a marked renoprotective effect of alpha-MSH treatment in conditions with urinary tract obstruction.

Voie excrétrice supérieure : physiologie, physiopathologie des obstructions et explorations fonctionnelles

The urine is transported from the renal papilla to the bladder through the upper urinary tract which allows this transport to be safe and comfortable, i.e., without any risk or pain for the kidney. This active transport depends on the smooth muscle contractile properties. The upper urinary tract is totally autonomous; this feature allows the preservation of its function after renal transplantation. However, despite its accessory role, the autonomous nervous system can modulate its activity. Upper urinary tract obstruction involves adaptative mechanisms which are different depending on the type (acute, chronic, acquired or congenital) of obstruction. Functional evaluations of the upper urinary tract are aimed at identify the urine transport conditions and the relationship between obstruction and clinical conditions such as hydronephrosis, pain or impaired renal function.

Altered expression of major renal Na transporters in rats with bilateral ureteral obstruction and release of obstruction

Urinary tract obstruction impairs urinary concentrating capacity and reabsorption of sodium. To clarify the molecular mechanisms of these defects, expression levels of renal sodium transporters were examined in rats with 24-h bilateral ureteral obstruction (BUO) or at day 3 or 14 after release of BUO (BUO-R). BUO resulted in downregulation of type 3 Na+/H+ exchanger (NHE3) to 41 +/- 14%, type 2 Na-Pi cotransporter (NaPi-2) to 26 +/- 6%, Na-K-ATPase to 67 +/- 8%, type 1 bumetanide-sensitive Na-K-2Cl cotransporter (BSC-1) to 20 +/- 7%, and thiazide-sensitive cotransporter (TSC) to 37 +/- 9%. Immunocytochemistry confirmed downregulation of NHE3, NaPi-2, Na-K-ATPase, BSC-1, and TSC. Consistent with this downregulation, BUO-R was associated with polyuria, reduced urinary osmolality, and increased urinary sodium and phosphate excretion. BUO-R for 3 days caused a persistant downregulation of NHE3 to 53 +/- 10%, NaPi-2 to 57 +/- 9%, Na-K-ATPase to 62 +/- 8%, BSC-1 to 50 +/- 12%, and TSC to 56 +/- 16%, which was associated with a marked reduction in the net renal reabsorption of sodium (616 +/- 54 vs. 944 +/- 24 micromol x min-1 x kg-1; P < 0.05) and phosphate (6.3 +/- 0.9 vs. 13.1 +/- 0.4 micromol x min-1. kg-1; P < 0.05) demonstrating a defect in renal sodium and phosphate reabsorption capacity. Moreover, downregulation of Na-K-ATPase and TSC persisted in BUO-R for 14 days, whereas NHE3, NaPi-2, and BSC-1 were normalized to control levels. In conclusion, downregulation of renal Na transporters in rats with BUO and release of BUO are likely to contribute to the associated urinary concentrating defect, increased urinary sodium excretion, and postobstructive polyuria.

Downregulation of renal aquaporins in response to unilateral ureteral obstruction

The expression of aquaporin-2 (AQP2) is decreased in rats with bilateral ureteral obstruction (BUO) and unilateral ureteral obstruction (UUO). Therefore, the expression of additional renal aquaporins (AQP1-4) and phosphorylated AQP2 (p-AQP2), known to play a role in urinary concentration, was examined in a Wistar rat model with 24 h of UUO. In obstructed kidneys, immunoblotting revealed a significant decrease in the expression of inner medullary AQP2 to 42 +/- 4, p-AQP2 to 23 +/- 5, AQP3 to 19 +/- 6, AQP4 to 11 +/- 5, and AQP1 to 64 +/- 8% of sham levels. AQP1 expression located in the proximal tubule decreased to 74 +/- 4% of sham levels (P < 0.05). Immunocytochemistry confirmed the downregulation of AQP3, AQP4, and p-AQP2. In contralateral nonobstructed kidneys, immunoblotting also revealed significant reductions of AQP1 in the inner medulla, outer medulla, and cortex, whereas expression of AQP2, AQP3, AQP4, and p-AQP2 was unchanged. Furthermore, we collected the urine from both obstructed and nonobstructed kidneys for 2 h, respectively, after 24 h of UUO. Urine collection from obstructed kidneys during 2 h after release of UUO revealed a significant reduction in urine osmolality and solute-free water reabsorption (T(c)H(2)O). Moreover, an increase in urine production and T(c)H(2)O was observed in contralateral kidneys. To examine whether vasopressin-independent mechanisms are involved in AQP2 regulation, vasopressin-deficient Brattleboro (BB) rats with 24 h of UUO were examined. Immunoblotting revealed downregulation of AQP2, p-AQP2, AQP3, and AQP1 in obstructed kidneys and downregulation of p-AQP2 and AQP1 in nonobstructed kidneys. In conclusion, 1) UUO is associated with severe downregulation of AQP2, AQP3, AQP4, and AQP1; thus all of these AQPs may play important roles in the impaired urinary concentrating capacity in the obstructed kidney; 2) the reduced levels of AQP1 in the nonobstructed kidney may contribute to the compensatory increase in urine production; and 3) downregulation of AQPs in BB rats supports the view that vasopressin-independent pathways may be involved in AQP2 and AQP3 regulation in the obstructed kidney.

Ureteropelvic Junction Obstruction: Some new Acquisitions about Etiology, Pathophysiology and Diagnostics

The etiopathogenesis of uretero-pelvic junction obstruction (UPJO) has been the subject of many speculations and it remains, in some ways, a debatable matter. Some recently reported thorough research refer to neuro-mediated pathogenetic mechanisms rather than (or together with) myogenic ones.

Advances in US, radioisotopic functional imaging, CT and RM contribute to differentiate the obstructive conditions from the non-obstructive ones and to afford today a better assessment of renal functional damage. Particularly, diuretic renography is a non-invasive test for characterization of the renal functional abnormalities resulting from UPJO. Helical CT with angiography is a useful technique for identification of crossing vessels (pyelo-vascular tangle) which can be used for the pre-surgical planning of endopyelotomy. Endoluminal ultrasonography can be used to guide the position of the incision for endopyelotomy (US-guided endopyelotomy).

Laboratory examinations are important to determine the overall renal function (serum creatinine, acid-base balance, serum electrolytes, etc.), urinary MCP-1 and NAG (markers of tubular damage), and to rule out urinary tract infections.

The management of UPJO (watchful waiting; either open or laparoscopic dismembered pyeloplasty; endoluminal procedures) is greatly influenced by the diagnostic evaluation.

The paper aims to outline the advances in both physiopathology and diagnostics of UPJO on the basis of a review of the literature.

Downregulation of AQP1, -2, and -3 after ureteral obstruction is associated with a long-term urine-concentrating defect

Previously, we demonstrated that 24 h of bilateral ureteral obstruction (BUO) and short-term release of BUO was associated with a decrease in the expression of aquaporin-2 (AQP2), polyuria, and a reduced urinary concentrating capacity (10). The purposes of the present study were to examine whether BUO and the long-term release of BUO (BUO-R) for 3, 14, and 30 days were associated with changes in the expression of renal AQP1, AQP2, and AQP3 and whether such changes were associated with parallel changes in urinary output and urinary concentrating capacity. Rats (n = 4-7 in each group) were kept in metabolic cages for measurements of urinary output. Kidneys were removed to determine the expression levels of AQP1, AQP2, and AQP3 by semiquantitative immunoblotting. AQP2 was downregulated after 24 h of BUO (42 +/- 3%). Downregulation of AQP2 persisted 3 (43 +/- 14%; P < 0.01) and 15 days after BUO-R (48 +/- 11%; P < 0.01) but was normalized 30 days after BUO-R. AQP3 showed a similar pattern. Moreover, AQP1 was downregulated in response to BUO (65 +/- 7%) and remained downregulated 3 days after BUO-R (41 +/- 5%), 14 days after BUO-R (57 +/- 8%), and 30 days after BUO-R (59 +/- 5%). BUO-R resulted in a significant polyuria that gradually decreased, although it remained significant at day 30. Urinary concentrating capacity remained significantly impaired when determined 3, 14, and 30 days after BUO-R in response to a 24-h period of thirst (1,712 +/- 270 vs. 2,880 +/- 91 mosmol/kgH2O at day 30, P < 0.05). In conclusion, the expression of AQP1, AQP2, and AQP3 were long-term downregulated after BUO-R, suggesting that dysregulation of aquaporins located at the proximal tubule, thin descending limb of the loop of Henle, and the collecting duct may contribute to the long-term polyuria and impairment of urinary concentrating capacity associated with obstructive nephropathy.

Histopathological and functional effects of radiation therapy in obstructive uropathy

Leukocyte influx into the cortex and medulla of the kidney is seen following acute ureteral obstruction. To investigate the macrophage influx and alterations in glomerular filtration rate (GFR) and to evaluate the effects of early radiation therapy on these parameters, we evaluated 20 rabbits in four groups. In the first group preoperative technetium-99m scanning preceding bilateral ureteral complete obstruction was performed. All rabbits received whole body irradiation of 1316 rads. Then the bilateral ureteral obstruction was released after 24 hours. Two hours after releasing, the last scanning was performed. The kidneys were immediately removed and histopathological examination was done. In the second group, all procedures except radiotherapy were done. The third group underwent sham laparotomy to assess the effects of surgical trauma on renal functions. The fourth group of rabbits was considered as control. We have observed an apparent macrophage influx into the cortex and medulla of the kidney following bilateral ureteral obstruction (p=0.000). However, irradiation reduced the infiltration significantly (p=0.000). Also in cases who received radiotherapy GFR was preserved to a significantly higher degree (p=0.000). We concluded that irradiation following acute ureteral obstruction has protective effects on renal function through abolition of the infiltrating cells.

Renal microcirculation and tissue damage during acute ureteral obstruction in the rat: effect of saline infusion, indomethacin and radiocontrast

Radiocontrast agents and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for the diagnosis and treatment of renal colic. We studied their impact during unilateral acute urinary outflow obstruction upon renal microcirculation and parenchymal integrity. Laser-Doppler and ultrasonic regional flow measurements demonstrated selective decline of outer medullary blood flow by 23 +/- 2% during an acute increase of intra-pelvic pressure to 50 to 55 cm H2O (N = 28, X +/- SEM, P < 0.01). In rats preconditioned with indomethacin, this manipulation reduced medullary blood flow by 50 +/- 4% (N = 16, P < 0.01 vs. obstruction alone), with cortical and total renal blood flow declining by 18 +/- 4% and 16 +/- 2%, respectively (P < 0.01). Unilateral obstruction alone for 24 hours in intact rats resulted in injury (hemorrhage and necrosis) to the papilla and fornix (formed laterally by inner stripe and medially by the inner medulla). These changes were detected as early as 30 minutes after ureteral ligature by staining for fragmented nuclear DNA (TUNEL). Mild damage of thick ascending limbs (mTALs) was associated with substantial medial fornix injury. Indomethacin markedly increased mTAL injury in obstructed kidneys, but attenuated inner medullary damage, both in the medial border of the urinary space and at the papilla. This latter protective effect, probably mediated by the decrease in intrapelvic pressure, was blunted by concomitant intravenous fluid load. Contrast media (iothalamate) and L-NAME (N omega nitro-L-arginine methyl ester) both augmented inner stripe and inner medullary damage in hydronephrotic kidneys. In rats concomitantly subjected to radiocontrast, indomethacin and L-NAME (an acute renal failure protocol, J Clin Invest 94:1069, 1994), unilateral obstruction augmented inner stripe hypoxic damage (65 +/- 6% vs. 24 +/- 11% of mTALs in contralateral kidneys, N = 7, P < 0.01). Injury was maximal at the fornix (93 +/- 6% vs. 39 +/- 14% of mTALs in the mid-inner stripe, P < 0.01) and extended to the outer stripe and medullary rays. Thus, in the rat acute ureteral obstruction alters medullary blood flow and within 24 hours produces medullary damage in both forniceal and inner medullary locations, that is exacerbated by concomitant measures which limit medullary oxygenation. Contrast studies, forced hydration and NSAIDs for renal colic are potentially harmful and their use should be re-evaluated.

Characterization of G proteins in obstructed kidneys

BACKGROUND

Urinary tract obstruction has a marked effect on renal function. Activation of phospholipases which results in incremental production of vasoactive eicosanoids may contribute to the hemodynamic changes characteristic of an obstructed kidney. G proteins play an important role in transmembrane signal transduction, which control phospholipase activities and eicosanoid production. The present study was designed to determine the presence of G proteins in obstructed kidneys in rats, and to characterize the differences between unilateral ureteral obstruction (UUO) and bilateral ureteral obstruction (BUO).

METHODS

Several G-protein alpha subunits (G alpha s, G alpha i1,2, and G alpha i3) and the beta subunit (G beta) were determined by immunoblotting and immunocytochemical techniques using specific antibodies against these G proteins.

RESULTS

Immunoblots demonstrated a decreased G alpha i3 content in the outer medullary tubules and a significantly lower G beta level in the glomeruli of UUO. In BUO, there was an increased level of G beta in the cortical tubules, and the G alpha s level was markedly reduced in the inner medullary tubules. Immunocytochemical studies revealed that these G proteins were predominantly localized in the brush border side of the cortical tubules. However, we could not demonstrate staining differences between UUO and BUO.

CONCLUSIONS

These results indicate that a modulation of G-protein-coupled transmembrane signal transduction may contribute to the renal functional changes in an obstructed kidney. A different level of expression of G-protein subunits between UUO and BUO may be a factor in the differences of hemodynamics and renal tubular damage between UUO and BUO.

The pathophysiology of ureteral obstruction

Ureteral obstruction can have a variety of causes intrinsic or extrinsic to the kidney. The effects of obstruction are examined from the perspectives of duration, severity, totality, and the presence of complicating factors. There is a difference in the postobstructive pathophysiology depending on whether one or both ureters were obstructed. Atrial natriuretic peptide may be important in postobstructive diuresis, and preliminary evidence suggests a role for it as protection against nephron ischemia in acute obstruction. The potential for recovery of renal function after relief of obstruction depends on the duration and degree of obstruction, the condition of the contralateral kidney, and the presence or absence of infection. Ability to acidify the urine to pH < 6.0 preoperatively may be a good predictor of the recovery potential of an obstructed kidney. Urine concentrations of lysosomal enzymes such as N-acetylglucosaminidase also may be useful for this purpose, as may measurement of creatinine clearance in urine obtained from a nephrostomy tube.

Increased plasma prorenin but not renin after bilateral ureteral ligation in dogs

Plasma prorenin is normally higher than renin and usually changes in response to the same stimuli. In dogs, plasma prorenin and renin disappear after bilateral nephrectomy, indicating that both are of renal origin. It has been proposed that prorenin may mediate tissue renin systems via its reversible intrinsic renin-like activity. The renin-angiotensin system has been implicated in the changes in renal function that occur with bilateral ureteral obstruction, but plasma prorenin has not been investigated. We therefore studied the effect of 48-hour bilateral obstruction on plasma prorenin in two groups of dogs: one was volume expanded (N = 5), while the other group (N = 6) was euvolemic. Plasma prorenin concentration increased fourfold in both groups, angiotensinogen increased twofold, while plasma renin activity was unchanged. Following release of obstruction, plasma renin fell slightly while prorenin and angiotensinogen remained elevated. There was a positive relationship between plasma prorenin and renin before (r = 0.63, P less than 0.05) and after (r = 0.76, P less than 0.01) obstruction. Post-obstruction, ERPF and GFR were subnormal but filtration fraction was maintained; the higher the ERPF and GFR the higher the plasma prorenin post-obstruction (r = 0.83, P less than 0.01 and r = 0.77, P less respectively; N = 11). These results show that impairment of renal function during bilateral obstruction is associated with an increase in plasma prorenin but not renin. Nonetheless, there is a positive relationship between plasma prorenin and renin both pre- and post-obstruction. Thus, preferential impairment of clearance of prorenin relative to renin may occur during bilateral obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of leukocyte depletion on the function of the postobstructed kidney in the rat

We have observed an influx of leukocytes, predominantly macrophages, into the cortex and medulla of the kidney following ureteral obstruction. To examine the potential contribution of these infiltrating cells to the decrease in GFR and RPF that occurs following ureteral obstruction, 16 male Lewis rats (wt 246.4 +/- 4.0 g) were studied in the awake state three hours after unilateral release of 24 hours of bilateral ureteral obstruction (BUO). Eight rats were not irradiated, and eight rats received 1315 rads one day prior to the obstruction. The leukocyte infiltrate following 24 hours of ureteral obstruction was quantified with and without prior irradiation in an additional eight rats. Irradiation reduced cortical infiltration (27.05 +/- 3.07 x 10(5) vs. 1.2 +/- 0.83 x 10(5) cells/g tissue) and medullary infiltration (13.6 +/- 1.79 x 10(5) vs. 0.86 +/- 0.45 x 10(5) cells/g tissue) of leukocytes following BUO (P less than 0.001 for both) and increased postobstruction GFR (1.58 +/- 0.12 vs. 2.97 +/- 0.15 ml/min/kg body wt, P less than 0.001). Eleven rats, six of which received irradiation, underwent sham laparotomy without BUO in order to assess the effect of irradiation alone on renal function. Irradiation had no effect on the renal function of non-obstructed rats. Urinary excretion of thromboxane B2 increased following BUO and this rise was significantly blunted by irradiation prior to BUO (9.53 +/- 2.14 vs. 32.46 +/- 4.95 vs. 19.03 +/- 1.94 pg/min). Fractional excretion of sodium and water was reduced by irradiation.(ABSTRACT TRUNCATED AT 250 WORDS)

Prior inhibition of vasoconstrictors normalizes GFR in postobstructed kidneys

The present studies were designed to analyze the potential contribution of angiotensin II and thromboxane A2 to the remarkable decrease in glomerular filtration rate (GFR) and renal plasma flow observed after unilateral release of 24-hour bilateral ureteral obstruction. Pretreatment of the animals with inhibitors of either thromboxane or angiotensin synthesis for 48 hours prior to and during obstruction eliminated the contribution of these vasoconstrictors. Inhibition of these vasoconstrictors during the period of obstruction results in a greater increase in renal plasma flow and GFR than when inhibition was accomplished after release of the obstruction. These data suggest a greater role for these vasoconstrictors in the decrease in GFR that occurs with obstruction. Simultaneous inhibition of thromboxane and angiotensin production normalized GFR of the postobstructed kidney. Administration of atrial peptide after release of obstruction in the different groups of rats resulted in further increases in GFR, urine flow and absolute sodium excretion. It is suggested that atrial peptide participates in the renal hemodynamic changes that occur in the postobstructed kidney.

Effects of obstruction on renal functions

Following ureteral obstruction there is a progressive fall in glomerular filtration rate (GFR) due to a reduction in single nephron glomerular filtration rate (SNGFR) and a reduced number of filtering nephrons. Renal plasma flow also declines after a transient, prostaglandin-dependent increase, due to afferent and efferent arteriolar vasoconstriction. The vasoactive hormones thromboxane A2 and angiotensin II are implicated in the pathogenesis of the vasoconstriction following ureteral obstruction and they also reduce the glomerular ultrafiltration coefficient by causing mesangial contraction. Ureteral obstruction also leads to profound changes in renal tubular cell function. These include altered sodium and water handling resulting in a post-obstructive diuresis and natriuresis and a failure to dilute or concentrate the urine. Potassium and divalent cation exchange is also affected, as is urinary acidification. Furthermore, the response of the tubule to hormones such as antidiuretic hormone and parathyroid hormone is impaired. The pathophysiology of these alterations in renal function is discussed.

The effect of E. coli infection on the prostaglandin synthesizing capacity of postobstructive rat kidney

The PGE2, PGI2, PGF2 alpha and TxA2 synthesizing activities were studied in an isolated microsomal fraction of rat kidney after temporary, unilateral ureter obstruction and E. coli infection. In the early phase of regeneration the synthesis of vasodilatory PGI2 was increased, whereas that of vasoconstrictory PGF2 alpha was decreased. An increased PGE2 synthesizing activity was observed when renal obstruction was associated with infection. The role of these changes in regenerating the haemodynamics and function of postobstructive kidney is discussed.

Tubuloglomerular feedback and interstitial pressure in obstructive nephropathy

The possible role of the tubuloglomerular feedback (TGF) mechanism in the altered glomerular hemodynamics and tubular reabsorption which occur with prolonged (24-hr) ureteral obstruction and the changes in renal interstitial hydrostatic and oncotic pressure which may modulate TGF sensitivity were examined. The proximal tubule stop-flow pressure (PSF) response to increased distal tubular flow rates (TGF activity) was determined in rats with sham operation, 24-hr unilateral ureteral obstruction (UUO), or 24-hr bilateral ureteral obstruction (BUO), both before and for 2 hr after relief of obstruction. Subcapsular hydrostatic pressure, lymph flow and oncotic pressure, clearance and excretory data were measured in the second series of animals. During and after release of UUO, TGF sensitivity was increased, as indicated by the marked decrease in the loop perfusion rate at which 50% of the maximum decrease in PSF occurred (the turning point of TGF activation). Interstitial oncotic pressure but not hydrostatic pressure was significantly increased in UUO kidneys. In BUO rats, the turning point for TGF activation was slightly higher than the controls and the change in PSF with maximum loop perfusion rates was reduced, indicating a blunting of the TGF response before and particularly during postobstructive diuresis after release of BUO. Interstitial hydrostatic and oncotic pressures were both slightly increased resulting in no changes in net interstitial Starling forces. We conclude that enhanced TGF sensitivity after release of prolonged UUO, associated with increased interstitial oncotic pressure, may play a role in preventing postobstructive diuresis, while the blunting of TGF sensitivity after BUO may contribute to this phenomenon.

Renal blood flow and vasodilatory ability prior to and following release of 24 hours bilateral ureteral obstruction in rats

Increased renal vascular resistance (RVR) is evident after 24 hours of uni- and bilateral ureteral obstruction (UUO and BUO). However, to what extent the RVR increase is due to vascular damage versus functional vasoconstriction, or whether obstructed kidneys possess the ability to reduce RVR in response to vasodilatory stimuli, is not clear. During 24 hours of BUO renal blood flow (RBF), recorded electromagnetically, was reduced to about 70% of control and continued to fall by another 18% during 1/2-1 hour after release of BUO. Infusion of imidazole, a thromboxane A2 synthetase blocker, did not reduce RVR after release of BUO. Whereas RBF autoregulation in response to reduced perfusion pressure was impaired, maximal proportional renal vasodilation induced by acetylcholine was increased, both prior to and after release of BUO, as compared to control and UUO. These different renal vasodilatory responses indicate that the RVR increase during BUO is largely due to a functional vasoconstriction that impairs autoregulatory vasodilation. In contrast, the RVR increase during UUO is probably mainly due to structural damage which does not prevent autoregulation of the RBF level attained.

Kidney pressures after the release of 24 hours of bilateral ureteral ligation in the rat

Kidney function was studied in rats after the release of 24 hours of bilateral ureteral ligation (BUL). After deligation, natriuresis was observed for 1 day while diuresis persisted up to 4 days. The possible defective collecting tubule to reabsorb sodium may improve within 1 day, since the urinary sodium concentration was well below the sham value. During the early phase of deligation, the glomerular filtration rate (GFR) averaged only 15 per cent of the sham value. Heterogeneity of the surface nephrons was apparent. About 17 per cent of the observed surface nephrons had no tubular fluid flow, suggesting possibly that these nephrons may not contribute to the kidney GFR. In the other 83 per cent of the nephrons, the stop-flow pressure, 29.0 mm. Hg, was lower than the sham value, 33.6 mm. Hg, whereas the proximal tubular pressure of 15.1 mm. Hg was significantly above the sham value of 13.2 mm. Hg. Both these factors may have induced a reduction in the effective filtration pressure, from 20.1 to 13.9 mm. Hg, and may have contributed to the reduction in GFR in those functioning nephrons. Four days later, a similar proportion of the surface nephrons still showed a marked reduction in function, whereas others had improved significantly. The proximal tubular pressure, the stop-flow and the effective filtration pressures approached the sham values. These improvements may be associated with an increase in GFR to 42 per cent of the sham value. It is suggested that the prolong suppression of the kidney GFR may not be due to the drastic change in the glomerular capillary pressure of the surface nephrons, at this latter period.