Humoral control of water and electrolyte excretion during water restriction

Animal models for diabetes insipidus

The hormone arginine vasopressin (AVP) is a nonapeptide synthesized by hypothalamic magnocellular nuclei and secreted from the posterior pituitary into the bloodstream. It binds to AVP receptor 2 in the kidney to promote the insertion of aquaporin channels (AQP2) and antidiuretic responses. AVP secretion deficits produce central diabetes insipidus (CDI), while renal insensitivity to the antidiuretic effect of AVP causes nephrogenic diabetes insipidus (NDI). Hereditary and acquired forms of CDI and NDI generate hypotonic polyuria, polydipsia, hyperosmolality, and hypernatremia. The AVP mutant (Brattleboro) rat is the principal animal model of hereditary CDI, while neurohypophysectomy, pituitary stalk compression, hypophysectomy, and mediobasal hypothalamic lesions produce acquired CDI. In animals, hereditary NDI is mainly caused by mutations in AVP2R or AQP2 genes, while acquired NDI is most frequently induced by lithium. We report here on the determinants of the intake and excretion of water and mineral salts and on the different types of DI in humans. We then describe the hydromineral characteristics of these animal models and the responses observed after administration of hypertonic NaCl or when they are fed with low-sodium diets. Finally, we report on the effects of drugs such as AVP analogues and/or oxytocin, another neuropeptide that increases sodium excretion in animal models and humans with CDI, and sildenafil, a compound that increases the expression and function of AQP2 channels in animal models and humans with NDI.

Reduction in central venous pressure enhances erythropoietin synthesis: role of volume-regulating hormones

AIMS

Erythropoiesis is a tightly controlled biological event, but its regulation under non-hypoxic conditions, however, remains unresolved. We examined whether acute changes in central venous blood pressure (CVP) elicited by whole-body tilting affect erythropoietin (EPO) concentration according to volume-regulating hormones.

METHODS

Plasma EPO, angiotensin II (ANGII), aldosterone, pro-atrial natriuretic peptide (proANP) and copeptin concentrations were measured at supine rest and up to 3 h during 30° head-up (HUT) and head-down tilt (HDT) in ten healthy male volunteers. Plasma albumin concentration was used to correct for changes in plasma volume and CVP was estimated through the internal jugular vein (IJV) aspect ratio with ultrasonography.

RESULTS

From supine rest, the IJV aspect ratio was decreased and increased throughout HUT and HDT respectively. Plasma EPO concentration increased during HUT (13%; P = 0.001, P for linear component = 0.017), independent of changes in albumin concentration. Moreover, ANGII and copeptin concentrations increased during HUT, while proANP decreased. The increase in EPO concentration during HUT disappeared when adjusted for changes in copeptin. During HDT, EPO, ANGII and copeptin concentrations remained unaffected while proANP increased. In regression analyses, EPO was positively associated with copeptin (β = 0.55; 95% CI = 0.18, 0.93; P = 0.004) irrespective of changes in other hormones and albumin concentration.

CONCLUSION

Reduction in CVP prompts an increase in plasma EPO concentration independent of hemoconcentration and hence suggests CVP per se as an acute regulator of EPO synthesis. This effect may be explained by changes in volume-regulating hormones.

Natriuretic hormones, endogenous ouabain, and related sodium transport inhibitors

The work of deWardener and colleagues stimulated longstanding interest in natriuretic hormones (NHs). In addition to the atrial peptides (APs), the circulation contains unidentified physiologically relevant NHs. One NH is controlled by the central nervous system (CNS) and likely secreted by the pituitary. Its circulating activity is modulated by salt intake and the prevailing sodium concentration of the blood and intracerebroventricular fluid, and contributes to postprandial and dehydration natriuresis. The other NH, mobilized by atrial stretch, promotes natriuresis by increasing the production of intrarenal dopamine and/or nitric oxide (NO). Both NHs have short (<35 min) circulating half lives, depress renotubular sodium transport, and neither requires the renal nerves. The search for NHs led to endogenous cardiotonic steroids (CTS) including ouabain-, digoxin-, and bufadienolide-like materials. These CTS, given acutely in high nanomole to micromole amounts into the general or renal circulations, inhibit sodium pumps and are natriuretic. Among these CTS, only bufalin is cleared sufficiently rapidly to qualify for an NH-like role. Ouabain-like CTS are cleared slowly, and when given chronically in low daily nanomole amounts, promote sodium retention, augment arterial myogenic tone, reduce renal blood flow and glomerular filtration, suppress NO in the renal vasa recta, and increase sympathetic nerve activity and blood pressure. Moreover, lowering total body sodium raises circulating endogenous ouabain. Thus, ouabain-like CTS have physiological actions that, like aldosterone, support renal sodium retention and blood pressure. In conclusion, the mammalian circulation contains two non-AP NHs. Identification of the CNS NH should be a priority.

mPGES-1-derived PGE2 mediates dehydration natriuresis

PGE(2) is a natriuretic factor whose production is elevated after water deprivation (WD) but its role in dehydration natriuresis is not well-defined. The goal of the present study was to investigate the role of microsomal prostaglandin E synthase-1 (mPGES-1) in dehydration natriuresis. After 24-h WD, wild-type (WT) mice exhibited a significant increase in 24-h urinary Na(+) excretion accompanied with normal plasma Na(+) concentration and osmolality. In contrast, WD-induced elevation of urinary Na(+) excretion was completely abolished in mPGES-1 knockout (KO) mice in parallel with increased plasma Na(+) concentration and a trend increase in plasma osmolality. WD induced a 1.8-fold increase in urinary PGE(2) output and a 1.6-fold increase in PGE(2) content in the renal medulla of WT mice, both of which were completely abolished by mPGES-1 deletion. Similar patterns of changes were observed for urinary nitrate/nitrite and cGMP. The natriuresis in dehydrated WT mice was associated with a significant downregulation of renal medullary epithelial Na channel-α mRNA and protein, contrasting to unaltered expressions in dehydrated KO mice. By quantitative RT-PCR, WD increased the endothelial nitric oxide synthase (eNOS), inducible NOS, and neuronal NOS expressions in the renal medulla of WT mice by 3.9-, 1.48-, and 2.6-fold, respectively, all of which were significantly blocked in mPGES-1 KO mice. The regulation of eNOS expression was further confirmed by immunoblotting. Taken together, our results suggest that mPGES-1-derived PGE(2) contributes to dehydration natriuresis likely via NO/cGMP.

Hypernatremia secondary to post-stroke hypodipsia: just add water!

Disorders in water metabolism may occur in stroke patients. When hypernatremia arises in this setting, it is usually secondary to the development of central diabetes insipidus or it is the result of neurologic lesions that prevent patients from having free access to water. Much rarer are the cases of post-stroke hypernatremia caused by hypodipsia secondary to lesions of the thirst center. We report the case of a patient with severe hypernatremia, probably secondary to post-hemorrhagic stroke hypodipsia. The hypernatremia seen in this case was corrected by scheduling the patient's water intake.

Tonicity-dependent induction of Sgk1 expression has a potential role in dehydration-induced natriuresis in rodents

In various mammalian species, including humans, water restriction leads to an acute increase in urinary sodium excretion. This process, known as dehydration natriuresis, helps prevent further accentuation of hypernatremia and the accompanying rise in extracellular tonicity. Serum- and glucocorticoid-inducible kinase (Sgk1), which is expressed in the renal medulla, is regulated by extracellular tonicity. However, the mechanism of its regulation and the physiological role of hypertonicity-induced SGK1 gene expression remain unclear. Here, we identified a tonicity-responsive enhancer (TonE) upstream of the rat Sgk1 transcriptional start site. The transcription factor NFAT5 associated with TonE in a tonicity-dependent fashion in cultured rat renal medullary cells, and selective blockade of NFAT5 activity resulted in suppression of the osmotic induction of the Sgk1 promoter. In vivo, water restriction of rats or mice led to increased urine osmolality, increased Sgk1 expression, increased expression of the type A natriuretic peptide receptor (NPR-A), and dehydration natriuresis. In cultured rat renal medullary cells, siRNA-mediated Sgk1 knockdown blocked the osmotic induction of natriuretic peptide receptor 1 (Npr1) gene expression. Furthermore, Npr1-/- mice were resistant to dehydration natriuresis, which suggests that Sgk1-dependent activation of the NPR-A pathway may contribute to this response. Collectively, these findings define a specific mechanistic pathway for the osmotic regulation of Sgk1 gene expression and suggest that Sgk1 may play an important role in promoting the physiological response of the kidney to elevations in extracellular tonicity.

Mild dehydration, vasopressin and the kidney: animal and human studies

Water balance depends essentially on fluid intake and urine excretion. Mild dehydration and the consequent hypertonicity of the extracellular fluid induce an increase in vasopressin secretion, thus stimulating urine concentrating processes and the feeling of thirst. The osmotic threshold for the release of vasopressin is lower than that for thirst and also shows appreciable individual variation. Sustained high levels of vasopressin and low hydration induce morphological and functional changes in the kidney. However, they could also be risk factors in several renal disorders, such as chronic renal failure, diabetic nephropathy and salt-sensitive hypertension.

Renal Na excretion in dehydrated and rehydrated adrenalectomized sheep maintained with aldosterone

The effect of water deprivation for 19 h on renal Na excretion of conscious adrenalectomized (ADX) sheep maintained on a constant intravenous infusion of aldosterone and cortisol (ADX-constant steroid sheep) was investigated. Both ADX and normal sheep showed large increases in renal Na excretion when they were deprived of water. ADX-constant steroid sheep also exhibited a normal postprandial natriuresis 3-6 h after feeding, whether or not water was available to drink. In another experiment, sheep deprived of water for 41 h were then allowed to drink water. Both normal and ADX-constant steroid sheep exhibited a large reduction of renal Na excretion in the 6 h after rehydration. Changes in plasma Na and K concentration and osmolality were similar in normal and ADX-constant steroid sheep during periods of dehydration and rehydration. These results show that change in aldosterone secretion is not a major factor in causing either dehydration-induced or postprandial natriuresis. Neither is it a major cause of rehydration-induced renal Na retention.

Osmoregulatory control of renal sodium excretion after sodium loading in humans

The hypothesis that renal sodium handling is controlled by changes in plasma sodium concentration was tested in seated volunteers. A standard salt load (3.08 mmol/kg body wt over 120 min) was administered as 0.9% saline (Isot) or as 5% saline (Hypr) after 4 days of constant sodium intake of 75 (LoNa+) or 300 mmol/day (HiNa+). Hypr increased plasma sodium by approximately 4 mmol/l but increased plasma volume and central venous pressure significantly less than Isot irrespective of diet. After LoNa+, Hypr induced a smaller increase in sodium excretion than Isot (48 +/- 8 vs. 110 +/- 17 micromol/min). However, after HiNa+ the corresponding natriureses were identical (135 +/- 33 vs. 139 +/- 39 micromol/min), despite significant difference between the increases in central venous pressure. Decreases in plasma ANG II concentrations of 23-52% were inversely related to sodium excretion. Mean arterial pressure, plasma oxytocin and atrial natriuretic peptide concentrations, and urinary excretion rates of endothelin-1 and urodilatin remained unchanged. The results indicate that an increase in plasma sodium may contribute to the natriuresis of salt loading when salt intake is high, supporting the hypothesis that osmostimulated natriuresis is dependent on sodium balance in normal seated humans.

The renin-aldosterone axis in patients with diabetes insipidus

OBJECTIVE

The objective of the present study was to investigate the renin-aldosterone axis in neurogenic diabetes insipidus in man, in view of the fact that profound abnormalities of this axis have been described in experimental animals with congenital neurogenic diabetes insipidus.

DESIGN AND PATIENTS

Nine patients with neurogenic diabetes insipidus and 11 healthy subjects (controls) were examined under basal conditions, following the standard 8-hour water deprivation test and 1 hour after a subsequent oral rehydration.

MEASUREMENTS

Plasma and urine osmolalities were determined by freezing point depression, plasma sodium and potassium by a method using an ion-selective electrode, plasma AVP, cortisol, aldosterone and plasma renin activity by radioimmunoassay.

RESULTS

Plasma renin activities under basal conditions were significantly higher in patients with diabetes insipidus than in controls (mean +/- SEM 23.4 +/- 6.6 vs 7.8 +/- 1.2 ng/l min). In the diabetes insipidus group, water deprivation caused a twofold increase in plasma renin activities (48 +/- 13.8 ng/l min) while in the control group plasma renin activity levels were not significantly altered (10.2 +/- 1.2 ng/l min). Rehydration did not alter plasma renin activity levels in either group (patients 50.4 +/- 13.2, controls 9.0 +/- 2.4 ng/l min). Plasma aldosterone concentrations under basal conditions did not differ between the two groups (patients 302.4 +/- 37, controls 326.4 +/- 36.5 pmol/l) and did not change in patients with diabetes insipidus after water deprivation or rehydration (307.5 +/- 67.2 and 385.5 +/- 91 pmol/l, respectively). Conversely, controls showed a significant decrease in plasma aldosterone levels after dehydration (201 +/- 27.9 pmol/l), which was attributed to the circardian variation in aldosterone secretion, as shown by a parallel decrease in plasma cortisol levels.

CONCLUSIONS

Patients with diabetes insipidus are hyper-reninaemic, probably because of chronic volume contraction. There is a dissociation between renin and aldosterone in patients with diabetes insipidus under basal conditions, which is exaggerated during water deprivation.

Effect of osmolality on cytosolic free calcium and aldosterone secretion

Alterations in extracellular osmolality have powerful inverse effects on basal and potassium- and angiotensin-stimulated aldosterone secretion. With the use of bovine glomerulosa cells grown in primary culture, the effects of alterations in osmolality on cytosolic calcium concentration ([Ca2+]c), efflux and uptake of 45Ca2+, and aldosterone secretion were determined. Alterations in osmolality, independent of sodium concentration, have inverse effects on aldosterone secretion, which are correlated with simultaneous changes in [Ca2+]c measured using fura-2. Reductions in osmolality cause dose-dependent biphasic increases in [Ca2+]c different from the monophasic increases in [Ca2+]c produced by increases in potassium concentration. Like potassium- and angiotensin-stimulated increases in [Ca2+]c, hypotonically induced increases in [Ca2+]c are associated with an increase in 45Ca2+ efflux. Reductions in osmolality also increased the uptake of 45Ca2+, an effect apparent at 2 min and persistent for at least 30 min. In the absence of extracellular calcium, reductions in osmolality, as increases in potassium concentration but not angiotensin, fail to increase [Ca2+]c, efflux of 45Ca2+, or aldosterone secretion. In conclusion, osmolality-induced alterations in aldosterone secretion are associated with parallel changes in [Ca2+]c, effects caused by alteration in the influx of extracellular calcium. On the basis of these and previous studies, we hypothesize that osmolality affects calcium influx by activating voltage-dependent or stretch-activated calcium channels.

Increase in plasma sodium enhances natriuresis in response to a sodium load unable to change plasma atrial peptide concentration

The influence of plasma sodium concentration in the control of sodium excretion was investigated in conscious, water-diuretic dogs. NaCl was infused for 60 min as a hypertonic or isotonic solution at a rate of 60 mumol NaCl min-1 kg-1 body wt. Plasma sodium concentration rose only during hypertonic infusion (P less than 0.05). Sodium excretion increased markedly with both infusions (hypertonic, from 2.4 +/- 0.6 to 105 +/- 27 mumol min-1; isotonic, from 3.9 +/- 1.3 to 58 +/- 17 mumol min-1). Fractional sodium excretion increased more during hypertonic than during isotonic infusion. Hypertonic infusion decreased diuresis from 3.1 +/- 0.5 to 1.3 +/- 0.6 ml min-1, while isotonic infusion elicited an increase from 3.9 +/- 0.5 to 7.2 +/- 0.7 ml min-1. Plasma renin activity and plasma aldosterone decreased markedly in both series (P less than 0.05), the relative changes in the two series being very similar. Central venous pressure increased (2.8 +/- 0.7 to 4.5 +/- 1.0 mmHg) during isotonic infusion but not significantly during hypertonic infusion. Arterial pressure, heart rate and plasma levels of atrial natriuretic peptide and catecholamines did not change measurably in either series. It is concluded that simultaneous increases in extracellular volume and sodium concentration cause a larger natriuretic response than a change in volume alone, and that a 40-fold increase in sodium excretion may occur without measurable changes in plasma atrial natriuretic peptide concentration.

Renal denervation does not prevent dehydration-induced natriuresis in sheep

Normal sheep or sheep in which the renal nerves had been extirpated were deprived of water for 2 days in order to determine whether changes in renal nerve activity contribute to natriuresis during water deprivation. Both groups of sheep showed a considerable natriuresis throughout the period of water deprivation and increases in plasma osmolality and plasma Na concentration. Renal denervation, as indicated by the absence of catecholamine fluorescence in kidney sections, was extensive. Previous experiments have suggested cerebral involvement in the induction of dehydration-induced natriuresis. The present results indicate that the efferent pathway mediating this cerebral influence on renal sodium excretion does not involve the renal nerves, suggesting a hormonal mechanism as the likely pathway.

Control of blood and extracellular volume

Blood and extracellular fluid volume are maintained within narrow limits despite considerable daily variations in the intake in salt and water. As summarized schematically in Figure 15, the urinary excretion of salt and water responds to changes in blood volume and arterial pressure. Volume-sensitive receptors located predominantly in the cardiac atria and arterial tree sense acute changes in the filling of the blood volume compartment, and urinary sodium excretion is adjusted in response to these detector mechanisms by virtue of alterations in both glomerular filtration rate and tubular sodium reabsorption. The reabsorption of sodium by the tubule responds to changes in extracellular fluid volume as well as to changes in filtered sodium load. Glomerular filtration rate and tubular reabsorption of sodium are influenced importantly by physical properties of the plasma in glomerular and peritubular capillaries and by the composition of the tubular fluid. The renal arterial perfusion pressure is a major factor regulating tubular reabsorption of sodium and water as signalled via changes in renal interstitial hydrostatic fluid pressure. Renal nerves and a variety of systemic and local hormones also influence tubular reabsorption of sodium and water directly by effects on transepithelial sodium transport and/or indirectly by altering renal medullary haemodynamics and the pressure-natriuresis-diuresis relationships. Thus, utilizing a variety of overlapping effector mechanisms that influence renal sodium and water excretion, mammalian organisms have achieved a high degree of stability of body fluid volumes. The fundamental relationship between arterial pressure and renal excretion appears to be the major mechanism which provides for the long-term control of body fluid volume. The sensitivity of the pressure-natriuresis-diuresis relationship is modified by the efferent pathways of the rapid-acting reflex and mechanoreceptor detectors of volume. Working together, these mechanisms provide a remarkable degree of rapid and long-term extracellular and blood volume stability.

Effect of plasma sodium on aldosterone secretion during angiotensin II stimulation in normal humans

Studies were carried out in normal male subjects (n = 6, age 20-35 years) to determine the interaction of angiotensin II and plasma sodium on aldosterone secretion. These relations were quantified by elevation of plasma sodium with an infusion of 5% sodium chloride (4 ml/kg/30 min i.v.) with measurements of plasma aldosterone, atrial natriuretic factor (ANF), and arginine vasopressin (AVP) over 3 hours. Two hours before sodium chloride infusion, an intravenous infusion of angiotensin II was begun at 0.5 or 5.0 ng/kg/min and continued throughout the study. Plasma potassium was maintained constant by the addition of potassium to the infusate. NaCl/KCl infusion raised plasma sodium 4 meq/l with no decreases of plasma potassium. Plasma aldosterone averaged 7 +/- 1.8 ng/dl before NaCl infusion in subjects infused with 0.5 ng angiotensin II and was not significantly reduced with sodium chloride infusion. Angiotensin II infused at 5 ng/kg/min resulted in average plasma aldosterone levels of 31 +/- 3.6 ng/dl, which sodium chloride infusion decreased to 16.6 +/- 1.3 ng/dl (p less than 0.05) in 60 minutes. Plasma aldosterone remained depressed for the remaining period of study. Plasma ANF increased from 40 to 60 pg/ml with sodium chloride infusion. We conclude that small physiological elevations of plasma sodium concentrations can signal substantial decreases of plasma aldosterone in normal human subjects in situations where plasma angiotensin II is moderately elevated. The precise mechanisms of these responses remain to be determined.

Adrenergic control of renin in euhydrated and water-deprived conscious dogs

These experiments evaluated the relative contributions of alpha- and beta-adrenoceptors to control of plasma renin activity (PRA) in conscious dogs in which PRA was elevated to two- and threefold basal levels by the orthostatic stress of passive quadruped standing and by 24-h water deprivation. All dogs were uninephrectomized and surgically prepared with chronically indwelling catheters in the aorta, vena cava, and remaining renal artery at least 10 days before experiments. Simultaneous direct renal arterial (ia) infusion of phenoxybenzamine and propranolol decreased PRA by 50% in euhydrated standing dogs and by 70% in dehydrated standing dogs without changing mean arterial pressure or heart rate. In euhydrated dogs, both ia phenoxybenzamine alone and ia propranolol alone significantly decreased PRA, but the effect of propranolol was greater than that of phenoxybenzamine. In dehydrated dogs, ia infusion of phenoxybenzamine alone did not significantly decrease PRA, whereas propranolol alone decreased PRA to nearly the same extent as combined ia alpha- and beta-adrenoceptor blockade. The majority of the adrenergically mediated component of PRA observed during orthostatic stress and dehydration in conscious dogs is therefore mediated by beta-adrenoceptors. However, PRA was similarly reduced whether propranolol was infused ia or intravenously. Thus the site of action of propranolol (intrarenal vs. extrarenal) could not be identified by these experiments.