Increased sodium transport by cortical collecting tubules from remnant kidneys

Pathophysiology and clinical management of hyperkalemia in chronic kidney disease

Adaptive increases in kidney and gastrointestinal excretion of K+ help to prevent hyperkalemia in patients with chronic kidney disease (CKD) as long as the glomerular filtration rate (GFR) remains >15-20 mL/min. K+ balance is maintained by increased secretion per functioning nephron, which is mediated by elevated plasma K+ concentration, aldosterone, increased flow rate, and enhanced Na+-K+-ATPase activity. Fecal losses of potassium also increase in CKD. These mechanisms are effective in preventing hyperkalemia if urine output is in excess of 600 mL/day and the GFR exceeds 15 mL/min. Development of hyperkalemia with only mild to moderate reductions in GFR should prompt a search for intrinsic disease of the collecting duct, disturbances in mineralocorticoid activity, and/or decreased delivery of sodium to the distal nephron. The initial approach to treatment is to review the patient's medication profile and whenever possible discontinue drugs that impair kidney K+ excretion. Patients should be educated on sources of K+ in the diet and should be strongly encouraged to avoid the use of K+ containing salt substitutes as well as herbal remedies since herbs may be a hidden source of dietary K+. Effective diuretic therapy and correction of metabolic acidosis are effective strategies to minimize the potential for hyperkalemia. Discontinuation or use of submaximal doses of renin-angiotensin blockers should be discouraged given the cardiovascular protective effect these drugs provide. Potassium binding drugs can be useful to enable use of these drugs and potentially allow liberalization of the diet in CKD patients.

Expression and functional characteristics of tubular transporters: P-glycoprotein, PEPT1, and PEPT2 in renal mass reduction and diabetes

Renal mass reduction is associated with a compromise in renal excretion, and thus dosages of drugs need to be adjusted to avoid adverse reactions and to ensure their effectiveness. A prototypic example is patients who had undergone transplantation due to a variety of causes, including diabetic nephropathy; the latter appears to be the major cause of renal failure requiring hemodialysis and transplantation. Conceivably, hyperglycemia with reduced renal mass interferes in the delivery of xenobiotics handled by various tubular transporters. In this investigation, effect of renal mass reduction/hyperglycemia on gene and protein expression of P-glycoprotein (Pgp), PEPT1, and PEPT2 was assessed. Also, [H(3)]glycylsarcosine uptake, a prototype of dipeptide, was measured in various groups of rats: sham-operated, uninephrectomized, streptozotocin-induced diabetes, and diabetic + uninephrectomized. An increase in Pgp, PEPT1, and PEPT2 expression was observed in kidneys of uninephrectomy rats, the highest being in the Pgp. Similarly, an increase was observed in diabetic rats who had undergone uninephrectomy, although less than those with nephrectomy alone. No differences were observed between sham-operated and diabetic groups. Increased uptake of [H(3)]glycylsarcosine was also seen in uninephrectomised rats. A modest uptake was observed in diabetic rats who had undergone uninephrectomy. The data suggest that uninephrectomy induces an increase in the expression and activity of transporters localized to renal tubular epithelial brush border. The fact that upregulation and activity of the peptide transporters were less in kidneys of diabetic animals who had undergone uninephrectomy compared with uninephrectomy alone suggests that hyperglycemia interferes in their expression and activity during the compensatory phase.

Hyperkalemia: An adaptive response in chronic renal insufficiency

BACKGROUND

Hyperkalemia is a common feature of chronic renal insufficiency, usually ascribed to impaired K+ homeostasis. However, various experimental observations suggest that the increase in extracellular [K+] actually functions in a homeostatic fashion, directly stimulating renal K+ excretion through an effect that is independent of, and additive to, aldosterone.

METHODS

We have reviewed relevant studies in experimental animals and in human subjects that have examined the regulation of K+ excretion and its relation to plasma [K+].

RESULTS

Studies indicate that (1) extracellular [K+] in patients with renal insufficiency correlates directly with intracellular K+ content, and (2) hyperkalemia directly promotes K+ secretion in the principal cells of the collecting duct by increasing apical and basolateral membrane conductances. The effect of hyperkalemia differs from that of aldosterone in that K+ conductances are increased as the primary event. The changes in principal cell function and structure induced by hyperkalemia are indistinguishable from the effects seen in adaptation to a high K+ diet.

CONCLUSIONS

We propose that hyperkalemia plays a pivotal role in K+ homeostasis in renal insufficiency by stimulating K+ excretion. In patients with chronic renal insufficiency, a new steady state develops in which extracellular [K+] rises to the level needed to stimulate K+ excretion so that it again matches intake. When this new steady state is achieved, plasma [K+] remains stable unless dietary intake increases, glomerular filtration rate falls, or drugs are given that disrupt the new balance.

Two apical multidrug transporters, P-gp and MRP2, are differently altered in chronic renal failure

Tubular function is altered in chronic renal failure (CRF). Whether drug secretion by renal tubules is modified in CRF is questioned because of frequent accumulation of various toxins in CRF. This function mainly involves ATP-dependent drug transporters, particularly P-glycoprotein (P-gp) and multidrug resistance-associated protein (MRP) 2, both present in apical membrane of epithelial cells. The present study was aimed at determining the changes in P-gp and MRP2 expression induced by experimental CRF in kidney and liver. The relationship between MRP2 and glutathione metabolism changes was examined because MRP2 transports GSSG and glutathione conjugates. Rats underwent either 80% subtotal nephrectomy (Nx) or sham operation, and determinations were performed 3 and 6 wk later. CRF induced a 70--200% rise in protein and mRNA expression of MRP2 after 3 and 6 wk post-Nx in remnant kidney and after 6 wk in liver. However, P-gp expression was unchanged by CRF. Relative to whole kidney mass, total MRP2 levels decreased by only 27% in Nx rats whereas total P-gp levels were reduced by 60%. Renal GSSG and total glutathione levels were increased by 30% in Nx rats, but glutathione-S-transferase (GST) activity was normal; liver GSSG levels and GST activity were reduced in Nx rats. In conclusion, CRF resulted in specific overexpression of MRP2 in kidney and liver. This could be an adaptative response to some elevated circulating toxins. The later MRP2 induction and different glutathione changes in liver compared with kidney suggest different mechanisms for MRP2 induction and/or action in these two tissues.

Potassium transport in the mammalian collecting duct

The mammalian collecting duct plays a dominant role in regulating K(+) excretion by the nephron. The collecting duct exhibits axial and intrasegmental cell heterogeneity and is composed of at least two cell types: collecting duct cells (principal cells) and intercalated cells. Under normal circumstances, the collecting duct cell in the cortical collecting duct secretes K(+), whereas under K(+) depletion, the intercalated cell reabsorbs K(+). Assessment of the electrochemical driving forces and of membrane conductances for transcellular and paracellular electrolyte movement, the characterization of several ATPases, patch-clamp investigation, and cloning of the K(+) channel have provided important insights into the role of pumps and channels in those tubule cells that regulate K(+) secretion and reabsorption. This review summarizes K(+) transport properties in the mammalian collecting duct. Special emphasis is given to the mechanisms of how K(+) transport is regulated in the collecting duct.

Metabolic support of collecting duct transport

The present studies address the metabolic processes that support the reabsorption of sodium and the secretion of bicarbonate in the interspersed but distinct principal and intercalated cells of the cortical collecting duct (CCD). In microperfused rabbit CCD, sodium reabsorption was measured by lumen-to-bath 22Na flux, and bicarbonate transport was assayed by microcalorimetry. Flux measurements were made before and after metabolic substrate changes or application of metabolic inhibitors. Both sodium reabsorption and bicarbonate secretion were dependent on oxidative metabolism (inhibited by antimycin A) and appeared to have no special dependence on glycolysis or the hexose-monophosphate shunt pathways. Endogenous substrates (in the absence of exogenous metabolic substrates) supported a small component of sodium transport; in contrast, bicarbonate reabsorption in the outer medullary collecting duct, which was studied for comparison, was fully supported by endogenous substrates. In the CCD, sodium reabsorption was supported best by a mixture of basolateral metabolic substrates (glucose and acetate, as a fatty acid), whereas bicarbonate secretion was fully supported by either glucose or acetate. Alanine, as a representative amino acid, was not an effective metabolic substrate. Another contrasting feature of the two transport processes was that bicarbonate secretion, and not sodium transport, was supported to some extent by luminal glucose. In sum, principal cells and intercalated cells differ not only in their morphology and function, but also in their metabolism.

Effects of chronic hyperfiltration on proximal tubule bicarbonate transport and cell electrolytes

The compensatory response to unilateral nephrectomy (UNX) was investigated by a combination of renal clearance, microperfusion, electron microprobe, and morphological techniques. Filtration rate was significantly elevated 21 days following UNX and associated with a marked stimulation of bicarbonate and fluid absorption in the proximal tubule. Analysis of kinetic data of bicarbonate transport demonstrated strong flow-dependent activation of bicarbonate absorption in both control and experimental condition. The bicarbonate level at which half-saturation (apparent Kd) of transport occurred decreased uniformly at higher flow rates, but maximal transport rates (apparent Vmax) in the proximal tubule doubled in the remnant kidney. The flow dependence of bicarbonate transport in control and experimental conditions can be explained by an apparent unstirred layer effect modifying radial bicarbonate gradients in the tubule. Both Na/H-exchange and electrogenic H secretion contribute to bicarbonate absorption, but only Na/H-exchange increased significantly in proximal tubules of UNX rats. Cell ion concentrations after UNX were unchanged in cortical tubules, consistent with proportionately enhanced apical and basolateral ion transport. Proximal tubule cell rubidium concentration measured after a 30-second rubidium infusion as an index of basolateral Na,K-ATPase activity was unchanged in UNX rats. Inasmuch as cell volume increased significantly (25%), these data are consistent with a proportionate and similar stimulation of rubidium uptake and Na,K-ATPase activity.

Short-term effects of uninephrectomy on electrical properties of the cortical collecting duct from rabbit remnant kidneys

Microelectrode techniques were used to assess the electrical properties of the collecting duct cell in the isolated perfused cortical collecting duct from remnant kidneys 3, 6, and 24 h after uninephrectomy (UNX); results were compared with those from sham-operated kidneys. Plasma aldosterone levels did not change during the time course after UNX. The lumen-negative transepithelial voltage was elevated significantly 3 h after UNX, and was increased further 24 h after UNX. The basolateral membrane voltage (VB) was elevated 6 h after UNX, and then was increased further at 24 h. Although the tight junction conductance and the fractional apical membrane resistance (fRA) were not altered at any time points after UNX, the apical membrane conductance as well as the transepithelial (GT) and basolateral membrane conductances increased 6 and 24 h after UNX. The changes in apical membrane voltage, GT, and fRA upon addition of luminal amiloride increased just 3 h after UNX, and then remained elevated at 6 and 24 h. The changes in apical membrane voltage and GT upon addition of luminal Ba2+, the changes in VB upon addition of bath ouabain, and the changes in VB, GT, and fRA upon raising bath K+ were not influenced 3 h after UNX, but increased at 6 and 24 h. At these latter periods after UNX, the transference number of Cl- of the basolateral membrane decreased significantly, whereas the transference number of K+ of the basolateral membrane increased significantly. Simultaneously, addition of Ba2+ to the bath caused the VB to hyperpolarize in parallel with decreases in GT and fRA. We conclude: (a) the initial effect of UNX (3 h) in the collecting duct cell is an increase in apical membrane Na+ conductance; (b) the delayed effects of UNX (6 and 24 h) are increases in apical membrane K+ conductance as well as basolateral membrane Na(+)-K+ pump activity and K+ conductance; (c) the hyperpolarization of VB at 6 and 24 h after UNX may result in the decrease of the ratio of the relative Cl- conductance to the relative K+ conductance of the basolateral membrane and also may increase passive K+ entry into the cell across the basolateral membrane; (d) these time-dependent electrical changes occur independently of plasma aldosterone levels.

Electrical properties of the rabbit cortical collecting duct from obstructed and contralateral kidneys after unilateral ureteral obstruction

Electrophysiological techniques were used to determine the electrical properties of the collecting duct (CD) cell in the isolated cortical collecting duct from obstructed (UUOOK) and contralateral (UUOCK) kidneys in rabbits 24 h after unilateral ureteral obstruction (UUO); results were compared with those from sham-operated kidneys. The lumen-negative transepithelial voltage and the basolateral membrane voltage (VB) were decreased in the UUOOK, and increased in the UUOCK. The transepithelial conductance (GT) was decreased in parallel with an increase in the fractional apical membrane resistance (fRA) and a decrease in apical membrane conductance in the UUOOK. By contrast, the GT was increased in parallel with increases in apical and basolateral membrane conductances in the UUOCK. The amiloride-sensitive changes in apical membrane voltage (VA), GT and fRA were lower in the UUOOK, but greater in the UUOCK. The changes in VA and GT upon raising the perfusate K+ concentration and upon addition of luminal Ba2+ were decreased in the UUOOK, and increased in the UUOCK. Addition of ouabain to the bath resulted in a smaller depolarization of VB in the UUOOK, but in a greater depolarization in the UUOCK. Upon lowering bath Cl-, the change in basolateral membrane electromotive force (delta EMF) was increased in the UUOOK, and decreased in the UUOCK. Reversely, upon raising bath K+, the delta EMF was decreased in the UUOOK, and increased in the UUOCK. We conclude: (a) the conductances of Na+ and K+ in the apical membrane, and active Na(+)-K+ pump activity and relative K+ conductance in the basolateral membrane are decreased in the UUOOK, and increased in the UUOCK; (b) the relative basolateral membrane Cl- conductance was increased in the UUOOK, and decreased in the UUOCK.

Effects of uninephrectomy on electrical properties of the cortical collecting duct from rabbit remnant kidneys

Microelectrode techniques were used to determine the Na+ and K+ transport properties of the collecting duct cell in the isolated cortical collecting duct (CCD) from rabbits 14 d after uninephrectomy (UNX); results were compared with those from sham-operated rabbits (control). UNX had no effects on plasma aldosterone levels. The CCDs from UNX rabbits exhibited structural hypertrophy. The lumen negative transepithelial voltage and the basolateral membrane voltage (VB) were elevated in the UNX group. Although the transepithelial conductance (GT) and the fractional apical membrane resistance (fRA) were not different between the two groups, the conductances of the apical and the basolateral membranes were increased, and the tight junction conductance was decreased in the UNX group. The amiloride-sensitive changes in apical membrane voltage (VA), fRA, and GT were greater in the UNX group. The changes in VA upon raising the perfusate K+ concentration and the changes in VA and GT upon addition of Ba2+ to the perfusate were elevated in the UNX group. Upon raising K+ in the bath, a large depolarization of VB was observed in the UNX group. Lowering the bath Cl- resulted in a small depolarization of VB in the UNX group. Addition of Ba2+ to the bath in the UNX group caused the VB to hyperpolarize in parallel with decreases in GT and fRA whereas in the control group it had no effect on VB. Addition of ouabain to the bath resulted in a large depolarization of VB in the UNX group. We conclude that (a) UNX stimulates conductances of Na+ and K+ in the apical membrane, active Na(+)-K+ pump activity, and K+ conductance in the basolateral membrane, independently of plasma aldosterone; (b) The basolateral membrane in the tubules of UNX rabbits is more selective to K+; and (c) the hyperpolarization of VB upon UNX may increase passive K+ entry into the cell across the basolateral membrane.

Response of cortical collecting ducts from remnant kidneys to arginine vasopressin

Chronic renal failure is associated with impaired urine concentration. Previous studies have demonstrated that cortical collecting ducts (CCD) from uremic rabbits (with remnant kidneys) have an impaired response to arginine vasopressin (AVP). To determine whether this defect is an early, integral component of compensatory renal growth by the remnant kidney, we studied the response of CCD derived from rabbits one week after 75% nephrectomy. At one week, hypertrophy and adaptation in sodium transport are fully developed, but azotemia and interstitial fibrosis are absent. The animals with remnant kidneys failed to respond normally to water deprivation and dDAVP (maximum urine osmolality 738 +/- 29.1 mOsm/kg compared to 1378 +/- 207 in sham operated). However, in isolated, perfused CCD from remnant kidneys, AVP stimulated hydraulic water permeability to the same extent as in normal CCD or CCD from sham operated animals. AVP-induced cAMP generation per mm tubule length was significantly higher in the CCD from remnant kidneys (137.4 +/- 14.5 fmol/mm) than in the control group (82.4 +/- 11.9 fmol/mm), but not different when expressed per micrograms protein. These studies demonstrate that one week after reduction in renal mass there is no defect in the response of CCD to AVP, suggesting that the mechanisms responsible for the hyposthenuria after loss of renal mass are not related to any intrinsic cellular changes that occur in CCD early during compensatory renal growth.

Compensatory hypertrophy and adaptation in the cortical collecting duct

The cortical collecting duct (CCD) undergoes hypertrophy and functional adaptation following reduction of renal mass. The nature and mechanisms of these changes have been investigated using microperfusion of isolated CCD from rabbit remnant kidneys. By 1 week after reduction of renal mass, tubule hypertrophy and increased sodium transport are fully developed. The transport adaptations are specific or selective, since bicarbonate transport in these CCD is unchanged. Mineralocorticoids may play an important role in the hypertrophy and increased sodium transport, since plasma aldosterone increases early after reduction of renal mass. Also, adrenalectomy abolishes the changes in size and sodium transport, even with supplementation of aldosterone to unstressed physiologic levels. Epidermal growth factor also has immediate effects on CCD sodium transport; however, the direction of the effect is opposite--an inhibition of transport.