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Sinclair De Frías J, Isha S, Olivero L, Raavi L, Narra SA, Paghdar S, Jonna S, Satashia P, Hannon R, Blasavage J, White L, Olanipekun T, Bansal P, Kiley S, Leoni JC, Nativí J, Lyle M, Thomas M, Sareyyupoglu B, Pham S, Smith M, Moreno Franco P, Patel P, Sanghavi D. Association between Impella device support and elevated rates of gout flares: a retrospective propensity-matched study. BMC Rheumatol 2024; 8:9. [PMID: 38424614 PMCID: PMC10902952 DOI: 10.1186/s41927-024-00380-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/09/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Impella is an advanced ventricular assist device frequently used as a bridge to heart transplantation. The association of Impella with increased rates of gout flares has not been studied. Our primary aim is to determine the rates of gout flares in patients on Impella support. METHODOLOGY A retrospective study was conducted between January 2017 and September 2022 involving all patients who underwent heart transplantation. The cohort was divided into two groups based on Impella support for statistical analysis. In patients receiving Impella support, outcome measures were compared based on the development of gout flares. 1:1 nearest neighbor propensity match, as well as inverse propensity of treatment weighted analyses, were performed to explore the causal relationship between impella use and gout flare in our study population. RESULTS Our analysis included 213 patients, among which 42 (19.71%) patients were supported by Impella. Impella and non-Impella groups had similar age, race, and BMI, but more males were in the Impella group. Gout and chronic kidney disease were more prevalent in Impella-supported patients, while coronary artery disease was less common. The prevalence of gout flare was significantly higher in Impella patients (30.9% vs. 5.3%). 42 Impella-supported patients were matched with 42 patients from the non-impella group upon performing a 1:1 propensity matching. Impella-supported patients were noted to have a significantly higher risk of gout flare (30.9% vs. 7.1%, SMD = 0.636), despite no significant difference in pre-existing gout history and use of anti-gout medications. Impella use was associated with a significantly increased risk of gout flare in unadjusted (OR 8.07), propensity-matched (OR 5.83), and the inverse propensity of treatment-weighted analysis (OR 4.21). CONCLUSION Our study is the first to identify the potential association between Impella support and increased rates of gout flares in hospitalized patients. Future studies are required to confirm this association and further elucidate the biological pathways. It is imperative to consider introducing appropriate measures to prevent and promptly manage gout flares in Impella-supported patients.
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Affiliation(s)
- Jorge Sinclair De Frías
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Lorenzo Olivero
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Lekhya Raavi
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Sai Abhishek Narra
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Smit Paghdar
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Sadhana Jonna
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Parthkumar Satashia
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Rachel Hannon
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Jessica Blasavage
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
- Associate Clinical Consultant, Abiomed, Jacksonville, FL, USA
| | - Layton White
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Titilope Olanipekun
- Department of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pankaj Bansal
- Department of Rheumatology, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Sean Kiley
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Juan Carlos Leoni
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Jose Nativí
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Melissa Lyle
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Mathew Thomas
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Basar Sareyyupoglu
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Si Pham
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Michael Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Parag Patel
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Devang Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA.
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Abstract
Multiple interacting checkpoints are involved in the pathophysiology of gout. Hyperuricemia is the key risk factor for gout and is considered a prerequisite for monosodium urate (MSU) crystal formation. Urate underexcretion through renal and gut mechanisms is the major mechanism for hyperuricemia in most people. Multiple genetic, environmental, and metabolic factors are associated with serum urate and alter urate transport or synthesis. Urate supersaturation is the most important factor for MSU crystal formation, and other factors such as temperature, pH, and connective tissue components also play a role. The nucleotide-binding oligomerization domain leucine-rich repeats and pyrin domain-containing protein 3 inflammasome plays a pivotal role in the inflammatory response to MSU crystals, and interleukin 1β is the key cytokine mediating the inflammatory cascade. Variations in the regulatory mechanisms of this inflammatory response may affect an individual's susceptibility to developing gout. Tophus formation is the cardinal feature of advanced gout, and both MSU crystals and the inflammatory tissue component of the tophus contribute to the development of structural joint damage owing to gout. In this article, we review the pathophysiologic mechanisms of hyperuricemia, MSU crystal formation and the associated inflammatory response, tophus formation, and structural joint damage in gout.
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Narang RK, Gamble G, Phipps-Green AJ, Topless R, Cadzow M, Stamp LK, Merriman TR, Dalbeth N. Do Serum Urate-associated Genetic Variants Influence Gout Risk in People Taking Diuretics? Analysis of the UK Biobank. J Rheumatol 2020; 47:1704-1711. [PMID: 32007933 DOI: 10.3899/jrheum.191005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether serum urate (SU)-associated genetic variants differ in their influence on gout risk in people taking a diuretic compared to those not taking a diuretic. METHODS This research was conducted using the UK Biobank Resource (n = 359,876). Ten SU-associated single-nucleotide polymorphisms (SNP) were tested for their association with gout according to diuretic use. Gene-diuretic interactions for gout association were tested using a genetic risk score (GRS) and individual SNP by logistic regression adjusting for relevant confounders. RESULTS After adjustment, use of a loop diuretic was positively associated with prevalent gout (OR 2.34, 95% CI 2.08-2.63), but thiazide diuretics were inversely associated with prevalent gout (OR 0.60, 95% CI 0.55-0.66). Compared with a lower GRS (< mean), a higher GRS (≥ mean) was positively associated with gout in those not taking diuretics (OR 2.63, 2.49-2.79), in those taking loop diuretics (OR 2.04, 95% CI 1.65-2.53), in those taking thiazide diuretics (OR 2.70, 2.26-3.23), and in those taking thiazide-like diuretics (OR 2.11, 95% CI 1.37-3.25). No nonadditive gene-diuretic interactions were observed. CONCLUSION In people taking diuretics, SU-associated genetic variants contribute strongly to gout risk, with a similar effect to that observed in those not taking a diuretic. These findings suggest that the contribution of genetic variants is not restricted to people with "primary" gout, and that genetic variants can play an important role in gout susceptibility in the presence of other risk factors.
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Affiliation(s)
- Ravi K Narang
- R.K. Narang, MBChB, G. Gamble, MSc, N. Dalbeth, FRACP, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland
| | - Greg Gamble
- R.K. Narang, MBChB, G. Gamble, MSc, N. Dalbeth, FRACP, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland
| | - Amanda J Phipps-Green
- A.J. Phipps-Green, MSc, R. Topless, BSc, M. Cadzow, PhD, T.R. Merriman, PhD, Department of Biochemistry, University of Otago, Dunedin
| | - Ruth Topless
- A.J. Phipps-Green, MSc, R. Topless, BSc, M. Cadzow, PhD, T.R. Merriman, PhD, Department of Biochemistry, University of Otago, Dunedin
| | - Murray Cadzow
- A.J. Phipps-Green, MSc, R. Topless, BSc, M. Cadzow, PhD, T.R. Merriman, PhD, Department of Biochemistry, University of Otago, Dunedin
| | - Lisa K Stamp
- L.K. Stamp, Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Tony R Merriman
- A.J. Phipps-Green, MSc, R. Topless, BSc, M. Cadzow, PhD, T.R. Merriman, PhD, Department of Biochemistry, University of Otago, Dunedin
| | - Nicola Dalbeth
- R.K. Narang, MBChB, G. Gamble, MSc, N. Dalbeth, FRACP, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland;
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Martin WP, le Roux CW. Comment on: Impact of serum uric acid on renal function after bariatric surgery: a retrospective study. Surg Obes Relat Dis 2019; 16:295-298. [PMID: 31839528 PMCID: PMC7116486 DOI: 10.1016/j.soard.2019.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 01/11/2023]
Affiliation(s)
- William P Martin
- Diabetes Complications Research Centre, Conway Institute, School of Medicine, University College Dublin, Dublin, Ireland
| | - Carel W le Roux
- Diabetes Complications Research Centre, Conway Institute, School of Medicine, University College Dublin, Dublin, Ireland; Division of Investigative Science, Imperial College London, London, United Kingdom
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Narang RK, Vincent Z, Phipps-Green A, Stamp LK, Merriman TR, Dalbeth N. Population-specific factors associated with fractional excretion of uric acid. Arthritis Res Ther 2019; 21:234. [PMID: 31718705 PMCID: PMC6852918 DOI: 10.1186/s13075-019-2016-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background Reduced renal clearance of uric acid is a major contributor to hyperuricemia. The aim of this study was to examine clinical and genetic variables associated with fractional excretion of uric acid (FEUA). Methods Participants (with and without gout) in the Genetics of Gout in Aotearoa study with available genotyping and FEUA data were included (n = 1713). Ten FEUA-associated loci detected within a genome-wide association study for serum urate in a European population were analysed. A polygenic score for FEUA was calculated in each ancestry group to model the cumulative effects of the genetic variants on FEUA. Associations between FEUA and both clinical variables and polygenic score were tested using linear regression models. Results The mean (SD) FEUA was 5.13 (2.70) % in Eastern Polynesian participants, 4.70 (5.89) % in Western Polynesian participants, and 5.89 (2.73) % in New Zealand European participants. Although association with FEUA was observed for SLC2A9 rs11942223 in New Zealand European participants (P = 2.39 × 10− 8), this association was not observed in Eastern or Western Polynesian participants. The polygenic score was positively associated with FEUA in all ancestry groups. In New Zealand European participants, body mass index, diuretic use, polygenic score, and male sex were associated with FEUA and explained 22% of FEUA variance in the regression model. In Eastern and Western Polynesian participants, the tested variables explained 10% and 4% of FEUA variance respectively. Conclusions Both clinical and genetic variables contribute to renal clearance of uric acid. SLC2A9 exerts effects on FEUA variance in people of European ancestry, but not in those of Polynesian ancestry. There is a large unexplained variance in FEUA, particularly in people of Polynesian ancestry.
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Affiliation(s)
- Ravi K Narang
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Zoe Vincent
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Amanda Phipps-Green
- Department of Biochemistry, University of Otago, 710 Cumberland Street, Dunedin, 9012, New Zealand
| | - Lisa K Stamp
- Department of Medicine, University of Otago, 2 Riccarton Avenue, Christchurch, 8140, New Zealand
| | - Tony R Merriman
- Department of Biochemistry, University of Otago, 710 Cumberland Street, Dunedin, 9012, New Zealand
| | - Nicola Dalbeth
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.
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Roch‐Ramel F, Besseghir K, Murer H. Renal Excretion and Tubular Transport of Organic Anions and Cations. Compr Physiol 2011. [DOI: 10.1002/cphy.cp080248] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cirrik S, Yavuzer BU, Oner G. Exercise-induced changes in renal URAT1 activity and expression in rats. Ren Fail 2010; 32:855-62. [PMID: 20662700 DOI: 10.3109/0886022x.2010.494805] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
During exercise, the plasma urate levels and urinary excretion increase due to the enhanced purine degradation in skeletal muscle. Although urate transporter-1 (URAT1) is the main transporter responsible for the reabsorption of filtered urate, potential changes in its activity and expression during exercise have not been studied yet. Therefore, the effect of heavy muscle activity on renal URAT1 activity and expression was investigated in this study. Wistar rats were used in the study and the experimental design consisted of three groups: a control group, an exercise group where animals were exhausted once a day for 5 days, and a hyperuricemia group, which was induced by an uricase inhibitor, oxonic acid. URAT1 activity measurements were performed in isolated proximal tubule segments and expression of URAT1 mRNA and protein levels were determined by the reverse transcription polymerase chain reaction and western blot analyses, respectively. Increased citrate synthase activity in soleus muscle of exercised animals proved the efficiency of our exercise protocol. Proteinuria, glucosuria, and hypoglycemia were observed only in exercised animals; however, plasma and urinary urate levels were found to be elevated in both exercising and hyperuricemia groups. Moreover, in both of the groups URAT1 transporter activity was found to be increased despite the significant decrease in URAT1 protein levels. Considering the similar changes of urate metabolism observed in both exercising and hyperuricemic rats, our results suggest that exercise-induced changes in URAT1 expression and activity depend on the increased urate concentration in plasma.
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Affiliation(s)
- Selma Cirrik
- Department of Physiology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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Sano S, Yamagami K, Morikawa T, Yoshioka K. Myelodysplastic syndrome complicated by central diabetes insipidus and cerebral salt wasting syndrome with peculiar change in magnetic resonance images. Intern Med 2010; 49:161-5. [PMID: 20075582 DOI: 10.2169/internalmedicine.49.2697] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Central diabetes insipidus (CDI) could occurs in patients with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML), because of infiltration of leukemic cells into the neurohypophysis or some other reason and it is closely associated with abnormalities of chromosome 7. We report a case of MDS with abnormalities of chromosome 7, presenting as CDI followed by deterioration of polyuria and hyponatremia with a decreased extracellular fluid volume. Magnetic resonance imaging (MRI) revealed symmetrically enhanced lesions in the hypothalamus. Fludrocortisone treatment normalized his serum sodium level and cerebral salt wasting syndrome (CSWS) was suspected.
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Affiliation(s)
- Soichi Sano
- Department of Internal Medicine, Osaka City General Hospital, Osaka
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Abstract
Many factors, including genetic components and acquired factors such as obesity and alcohol consumption, influence serum uric acid (urate) concentrations. Since serum urate concentrations are determined by the balance between renal urate excretion and the volume of urate produced via purine metabolism, urate transporter genes as well as genes coding for enzymes involved in purine metabolism affect serum urate concentrations. URAT1 was the first transporter affecting serum urate concentrations to be identified. Using the characterization of this transporter as an indicator, several transporters have been shown to transport urate, allowing the construction of a synoptic renal urate transport model. Notable re-absorptive urate transporters are URAT1 at apical membranes and GLUT9 at basolateral membranes, while ABCG2, MRP4 (multidrug resistance protein 4) and NPT1 are secretive transporters at apical membranes. Recent genome-wide association studies have led to validation of the in vitro model constructed from each functional analysis of urate transporters, and identification of novel candidate genes related to urate metabolism and transport proteins, such as glucokinase regulatory protein (GKRP), PDZK1 and MCT9. However, the function and physiologic roles of several candidates, as well as the influence of acquired factors such as obesity, foods, or alcoholic beverages, remain unclear.
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Fung MM, Rana BK, Tang CM, Shiina T, Nievergelt CM, Rao F, Salem RM, Waalen J, Ziegler MG, Insel PA, O'Connor DT. Dopamine D1 receptor (DRD1) genetic polymorphism: pleiotropic effects on heritable renal traits. Kidney Int 2009; 76:1070-80. [PMID: 19675531 DOI: 10.1038/ki.2009.306] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Because dopamine D(1) receptors (DRD1) influence renal sodium transport and vascular hemodynamics, we examined whether genetic polymorphisms play a role in renal function. We conducted polymorphism discovery across the DRD1 open reading frame and its 5'-UTR and then performed association studies with estimated glomerular filtration rate (eGFR), plasma creatinine (pCr), and fractional excretion of uric acid (FeUA). We used a twin/family group of 428 subjects from 195 families and a replication cohort of 677 patients from the Kaiser health-care organization sampled from the lower percentiles of diastolic blood pressures. Although the coding region lacked common non-synonymous variants, we identified two polymorphisms in the DRD1 5'-UTR (G-94A, A-48G) that occurred with frequencies of 15 and 30%, respectively. In the twin/family study, renal traits were highly heritable, such that DRD1 G-94A significantly associated with eGFR, pCr, and FeUA. Homozygotes for the G-94A minor allele (A/A) exhibited lower eGFR, higher pCr, and lower FeUA. No effects were noted for DRD1 A-48G. Patients in the Kaiser group had similar effects of G-94A on eGFR and pCr. Kidney cells transfected with the -94A variant but not the wild type vectors had increased receptor density. Because the -94A allele is common and may reduce glomerular capillary hydrostatic pressure, G-94A profiling may aid in predicting survival of renal function in patients with progressive renal disease.
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Affiliation(s)
- Maple M Fung
- Department of Medicine, Veterans Affairs San Diego Healthcare System and University of California at San Diego, La Jolla, California 92093-0838, USA
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Development of Severe Hyponatremia due to Salt-Losing Nephropathy after Esophagectomy for Esophageal Cancer. Case Rep Med 2009; 2009:241283. [PMID: 19888422 PMCID: PMC2771150 DOI: 10.1155/2009/241283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 09/07/2009] [Indexed: 11/24/2022] Open
Abstract
A 72-year-old woman was admitted to our hospital for esophagectomy for esophageal cancer. On the third postoperative day, she developed polyuria (3.8 L/day), massive natriuresis, hyponatremia (112 mEq/L), hyperkalemia (5.6 mEq/L), and decreased central venous pressure, which was refractory to isotonic saline infusion. Laboratory findings indicated proximal tubular injury (high urinary β2-microglobulin, coexistence of hypouricemia) together with reduced aldosterone action at the cortical collecting duct. A diagnosis of salt-losing nephropathy was made and sodium correction was done with 3% saline and fludrocortisone. She responded well to therapy. The cause of hyponatremia was considered renal tubular dysfunction together with elevated antidiuretic hormone level. Postoperatively, it is important to look for the development of salt-losing nephropathy.
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Decaux G, Musch W. Clinical laboratory evaluation of the syndrome of inappropriate secretion of antidiuretic hormone. Clin J Am Soc Nephrol 2008; 3:1175-84. [PMID: 18434618 DOI: 10.2215/cjn.04431007] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Hyponatremia secondary to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a frequent cause of hypotonicity. Although the differential diagnosis with other causes of hypotonicity such as salt depletion is sometimes challenging, some simple and readily available biologic parameters can be helpful in the diagnosis of SIADH. In SIADH, urea is typically low; this is less specific for elderly patients, for whom lower clearance of urea accounts for higher values. Low levels of uric acid are more often seen in SIADH (70%) compared with salt-depleted patients (40%). Typically, patients with SIADH will show a lower anion gap with nearly normal total CO2 and serum potassium, this despite dilution. In patients with hyponatremia secondary to hypocorticism, total CO2 is usually lower than in nonendocrine SIADH despite low urea and uric acid levels. Urine biology can also be helpful in diagnosis of SIADH because patients with SIADH have high urine sodium (Na; >30 mEq/L), and most of them will have a high fractional excretion of Na (>0.5% in 70% of cases), reflecting salt intake. Conversely, low urine Na in patients with SIADH and poor alimentation is not rare. Finally, measurement of urine osmolality is useful for the diagnosis of polydipsia and reset osmostat and could further help in the choice of therapeutic strategy because patients with low urine osmolality will benefit from water restriction or urea, whereas those with high urine osmolality (>600 mOsm/kg) would be good candidates for V2 antagonist.
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Affiliation(s)
- Guy Decaux
- Research Unit for the Study of Hydromineral Metabolism, Department of General Internal Medicine, Erasme University Hospital, Route de Lennik, 808, B-1070 Brussels, Belgium.
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Siani A, Russo P, Paolo Cappuccio F, Iacone R, Venezia A, Russo O, Barba G, Iacoviello L, Strazzullo P. Combination of renin-angiotensin system polymorphisms is associated with altered renal sodium handling and hypertension. Hypertension 2004; 43:598-602. [PMID: 14967847 DOI: 10.1161/01.hyp.0000117985.57001.b3] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Genes of the renin-angiotensin-aldosterone system (RAAS) are natural candidates for sodium homeostasis and blood pressure regulation. To investigate the effect of a combination of polymorphisms of RAAS genes on renal sodium handling and blood pressure, 918 participants to the Olivetti Heart Study were genotyped for the following polymorphisms: I/D of angiotensin converting enzyme (ACE), M235T of angiotensinogen (AGT), A1166C of angiotensin II type-1 receptor (AT1R), and C-344T of aldosterone synthase (CYP11B2). The segmental renal sodium handling was evaluated by the fractional excretions of exogenous lithium (FE-Li), uric acid (FE-UA), and sodium (FE-Na). Twenty-eight carriers of triple homozygosity for M (AGT), A (AT1R), and C (CYP11B2) in the presence of the D allele of ACE (DD/ID) showed lower FE-Li (20.0%+/-5.9% versus 25.0%+/-7.5%; P=0.004; mean+/-sD), FE-UA (6.3%+/-2.0% versus 8.2%+/-2.7%; P=0.001), and FE-Na (0.96%+/-0.41% versus 1.22%+/-0.61%; P=0.004) as compared with all other allelic combinations (n=890), independently from age and body mass, suggesting an enhanced rate of proximal tubular sodium reabsorption. The carriers of the MM, AA, CC, DD/ID combination showed a substantially higher probability of being hypertensive (OR: 3.4 [(99% CI: 1.1 to 10.1]), independently of age and body mass. This relatively rare combination of allelic variants of candidate genes of the RAAS is associated with a significant alteration in proximal renal sodium handling and with higher risk of hypertension, suggesting that a combination of polymorphic variants at different candidate loci may affect phenotypic expression even in the absence of detectable effects of each variant at any single locus.
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Affiliation(s)
- Alfonso Siani
- Institute of Food Sciences, CNR, Via Roma, 52 A/C, 83100 Avellino, Italy.
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Strazzullo P, Barba G, Cappuccio FP, Siani A, Trevisan M, Farinaro E, Pagano E, Barbato A, Iacone R, Galletti F. Altered renal sodium handling in men with abdominal adiposity: a link to hypertension. J Hypertens 2001; 19:2157-64. [PMID: 11725158 DOI: 10.1097/00004872-200112000-00007] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Central adiposity, insulin resistance and hypertension are clearly interrelated but the mechanisms underlying this association have not been thoroughly elucidated. As renal sodium handling plays a central role in salt-sensitive forms of hypertension, we investigated the relation of renal tubular sodium handling to abdominal adiposity, blood pressure and insulin sensitivity. DESIGN Population-based study. PARTICIPANTS Five hundred and fifty-five untreated Olivetti male workers, aged 25-75 years. SETTING Olivetti factory medical centers in Pozzuoli and Marcianise (Naples, Italy) MAIN OUTCOME MEASURES Anthropometric indices, serum insulin, homeostatic model assessment index of insulin sensitivity, blood pressure, fractional excretions of uric acid and exogenous lithium (as markers of renal tubular sodium handling). RESULTS In univariate analysis, measures of central adiposity (i.e. sagittal abdominal diameter and umbilical circumference) were directly correlated with serum insulin (P < 0.001) and blood pressure levels (P < 0.001) and inversely associated with the fractional excretions of uric acid and lithium (P = 0.01-0.001). In multiple linear regression analysis, the same anthropometric indices but not the measures of peripheral adiposity (arm circumference and tricipital skinfold thickness), were significant predictors of the fractional excretion of uric acid and lithium, independently of age, blood pressure and serum insulin levels (P = 0.01-0.001). CONCLUSIONS Abdominal adiposity was associated with altered renal tubular sodium handling apart from insulin resistance and high blood pressure. The data indicate that men with prevalent abdominal adiposity have an enhanced rate of tubular sodium reabsorption, mainly at proximal sites. These findings provide a possible mechanistic link between central adiposity and salt-dependent hypertension.
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Affiliation(s)
- P Strazzullo
- Department of Clinical and Experimental Medicine, Unit of Clinical Genetics and Pharmacology, Hypertension and Mineral Metabolism, Federico II University of Naples Medical School, Naples, Italy.
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Decaux G, Prospert F, Soupart A, Musch W. Evidence that chronicity of hyponatremia contributes to the high urate clearance observed in the syndrome of inappropriate antidiuretic hormone secretion. Am J Kidney Dis 2000; 36:745-51. [PMID: 11007676 DOI: 10.1053/ajkd.2000.17623] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The high fractional excretion (FE) of uric acid observed in hyponatremia associated with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is commonly attributed to the volume-expanded state, although volume expansion in normonatremic volunteers is unable to increase urate clearance to a degree similar to that in SIADH. The goal of the present study is to analyze whether hyponatremia by itself could influence the FE of uric acid, as well as the effects of intravascular volume and glomerular filtration rate on FE of uric acid in SIADH. This study examines the effects of a 2-L infusion of isotonic saline over 24 hours on FE of uric acid in 9 normonatremic volunteers and 17 hyponatremic patients with SIADH. We also studied the FE of uric acid in 6 patients with SIADH with only mild water retention and the urate and creatinine clearances in 18 hyponatremic patients with SIADH before and after normalization of serum sodium levels by water restriction. When infusing 2 L of isotonic saline over 24 hours in healthy subjects, there was a decrease in plasma protein concentration of 8%, suggesting a similar degree of volume expansion than in patients with SIADH. The FE of uric acid did not increase to the same extent (9% +/- 1.5% versus 17% +/- 1.5%; P: < 0.01). Conversely, in 6 hyponatremic patients with mild water retention (1 L), the FE of uric acid was still high despite indirect signs of only a small increase in plasma volume. The mainstay of these observations is that chronicity of hyponatremia by itself could affect urate excretion. We also observed that in the patients with SIADH, high FE of uric acid inversely correlated with glomerular filtration rate (r = -0.66; P: < 0.01) only during the hyponatremic state. These data suggest that hyponatremia by itself, combined with mild volume expansion and glomerular filtration rate, has a role in the high FE of uric acid in the SIADH.
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Affiliation(s)
- G Decaux
- Service de Médecine Interne Générale, Hôpital Universitaire
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Decaux G, Prospert F, Namias B, Soupart A. Hyperuricemia as a clue for central diabetes insipidus (lack of V1 effect) in the differential diagnosis of polydipsia. Am J Med 1997; 103:376-82. [PMID: 9375705 DOI: 10.1016/s0002-9343(97)00165-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE In the differential diagnosis of patients with polyuria-polydipsia one must distinguish usually between primary polydipsia (PP) and central diabetes insipidus (CDI). The first situation is a state of volume expansion and the second of volume contraction. We evaluate whether serum uric acid determination could help to differentiate between the two conditions. PATIENTS AND METHODS We analyzed the score of 13 consecutive patients with CDI, 7 patients with PP, and 7 patients with nephrogenic diabetes insipidus (NDI). Serum uric acid concentration was available during normonatremia without treatment with 1-desamino-8-D-arginine vasopressin (dDAVP), during mild dehydration and during treatment with dDAVP. In 8 of these patients plasma renin activity (PRA), urate, urea and creatinine clearances were also available. These data were also obtained in the patients with NDI. In 1 patient with CDI, we studied the effect on urate clearance of dDAVP, which stimulates exclusively the V2 receptors, and of triglycyl-lysine-vasopressin (TGLV), a potent V1-receptor agonist. RESULTS Normonatremic polydypsic patients with CDI presented an increase in uric acid concentration (7.1 +/- 2.2 mg/dL), whereas in the PP group the value was decreased (3 +/- 0.75 mg/dL; P <0.001). All the normonatremic PP presented a serum uric acid concentration lower than 5 mg/dL, whereas all the normonatremic CDI patients, exept 1, presented a value higher than 5 mg/dL. In both groups blood urea concentration was decreased as a consequence of high renal clearances. The hyperuricemia of CDI was related to low uric acid clearances. Patients with hypernatremia and NDI presented a lower increase in serum uric acid concentration than those with similar levels of hypernatremia and CDI (NDI: 5.7 +/- 0.8 mg/dL and CDI: 7.9 +/- 2.3 mg/dL; P <0.05) and the NDI patients presented an urate clearance corrected for creatinine clearance which was significantly higher than in CDI (9% +/- 3% and 4% +/- 1.1%; P <0.01). When the patients with CDI were treated with dDAVP and normalyzed their PRA (0.9 +/- 0.4 ng/mL/h) we observed still mild hyperuricemia compared to controls (5.5 +/- 1.4 mg/dL and 4.3 +/- 0.9 mg/dL; P <0.01) and a low fractional excretion of filtered uric acid (6.5% +/- 1.7% compared to 8.2% +/- 2% in controls; P <0.05). Acute administration of dDAVP, stimulating the V2 receptors, in one patient with CDI, had no effect on urate clerance, while TGLV, which stimulates the V1 receptor, increased urate clearance. CONCLUSION The presence of an serum uric acid concentration higher than 5 mg/dL in polyuric polydipsic patients is highly suggestive of CDI. Even when these patients are treated with dDAVP many of them remain hyperuricemic, and this seems to be the consequence of a lack of V1 receptor stimulation.
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Affiliation(s)
- G Decaux
- Unité de Recherche du Métabolisme Hydrominéral, Hôpital Universitaire Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Sennesael JJ, Lamote JG, Violet I, Tasse S, Verbeelen DL. Divergent effects of calcium channel and angiotensin converting enzyme blockade on glomerulotubular function in cyclosporine-treated renal allograft recipients. Am J Kidney Dis 1996; 27:701-8. [PMID: 8629631 DOI: 10.1016/s0272-6386(96)90106-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The effects of amlodipine and perindopril on renal hemodynamics and tubular function in cyclosporine-treated hypertensive renal allograft recipients were evaluated in a randomized, double-blind crossover fashion. Ten patients were studied after a 2-week placebo run-in and, after 8 weeks of active treatment, allowing a 2-week placebo washout between treatments. At the end of each period, glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were measured as 51Cr-EDTA and 123I-hippuran clearance, respectively, and tubular function evaluated by the lithium clearance technique was determined. Both drugs maintained GFR and ERPF and lowered mean arterial pressure (MAP, mm Hg) to a similar extent (time x treatment, P = 0.466): amlodipine from 126.9 +/- 2.5 to 115.9 +/- 2.2; perindopril from 126.9 +/- 2.5 to 117.9 +/- 3.9 (time effect of all treatments together, P = 0.003). Accordingly, renal vascular resistance (RVR, mm Hg/mL/min/1.73 m2) was equally reduced (time x treatment, P = 0.955): amlodipine from 0.36 +/- 0.03 to 0.30 +/- 0.02; perindopril from 0.36 +/- 0.03 to 0.32 +/- 0.01 (time effect all treatments together, P = 0.043). Sodium clearance and fractional excretion of sodium were not affected by either drug. Output of fluid from the proximal tubules measured as clearance of lithium (CLi, mL/min) and uric acid (CUr, mL/min) was higher after amlodipine than after perindopril (CLi 19.1 +/- 2.1 v 16.5 +/- 1.7, P =0.036 and CUr 7.0 +/- 0.6 v 5.9 +/- 0.4, P = 0.007). As a consequence, after amlodipine, distal absolute reabsorption of sodium was higher (DARNa 2.57 +/- 0.28 v 2.19 +/- 0.22 mEq/min, P = 0.027) and serum uric acid was lower (5.9 +/- 0.3 v 6.7 +/- 0.4 mg/dL, P = 0.001) in comparison with perindopril. In cyclosporine-treated renal allograft hypertensives, amlodipine and perindopril lower blood pressure equally and reduce RVR to the same extent. Overall sodium excretion is not affected by either agent. Urate clearance is higher and serum uric acid lower on amlodipine as compared with perindopril.
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Affiliation(s)
- J J Sennesael
- Renal Unit, Academisch Ziekenhuis, Vrije Universiteit Brussel, Belgium
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Maesaka JK, Venkatesan J, Piccione JM, Decker R, Dreisbach AW, Wetherington J. Plasma natriuretic factor(s) in patients with intracranial disease, renal salt wasting and hyperuricosuria. Life Sci 1993; 52:1875-82. [PMID: 8502124 DOI: 10.1016/0024-3205(93)90008-q] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
To test our hypothesis that a circulating factor(s) may be causing the renal salt and urate wasting in patients (pts) with intracranial diseases, we exposed rats to the plasma of these patients and studied sodium and lithium transport. We selected 21 neurosurgical pts, 13 of whom had increased fractional excretion (FE) of urate, and 14 age and sex-matched controls. Plasma from pts and controls were injected IP (0.5 mL) and infused, 0.2 ml prime and 1.8 mL at 0.01 mL/min, to Sprague Dawley rats anesthetized with Inactin. Renal transport of sodium (Na), lithium (Li) and potassium (K) was determined. There were higher mean +/- SEM for FENa, 0.59 +/- 0.07% vs 0.29 +/- 0.05%, P < 0.01, FELi, 36.6 +/- 1.9% vs 24.0 +/- 1.6%, P < 0.001 and K excretion rates, 1.69 +/- 0.13 vs 1.31 +/- 0.09 mumol/min, p < 0.02, in rats infused with plasma of pts as compared to controls, respectively. FENa decreased with increasing dilution of plasma of 2 pts with ICD. There was no difference in mean weight of rats, blood pressure, urine flow rate or insulin clearance between pts and controls. These data suggest that pts with ICD have a plasma factor(s) which decreases net Na, Li and K reabsorption.
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Affiliation(s)
- J K Maesaka
- Department of Medicine, Long Island Jewish Medical Center, New Hyde Park 11042
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Kinne R, Kinne‐Saffran E. Renal Plasma Membranes: Isolation, General Properties, and Biochemical Components. Compr Physiol 1992. [DOI: 10.1002/cphy.cp080245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Urate Transport in Mammalian Nephron. Nephrology (Carlton) 1991. [DOI: 10.1007/978-3-662-35158-1_144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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