Increased Na/H antiport activity and abundance in uremic red blood cells

Lithium in the Kidney: Friend and Foe?

Trace amounts of lithium are essential for our physical and mental health, and administration of lithium has improved the quality of life of millions of patients with bipolar disorder for >60 years. However, in a substantial number of patients with bipolar disorder, long-term lithium therapy comes at the cost of severe renal side effects, including nephrogenic diabetes insipidus and rarely, ESRD. Although the mechanisms underlying the lithium-induced renal pathologies are becoming clearer, several recent animal studies revealed that short-term administration of lower amounts of lithium prevents different forms of experimental AKI. In this review, we discuss the knowledge of the pathologic and therapeutic effects of lithium in the kidney. Furthermore, we discuss the underlying mechanisms of these seemingly paradoxical effects of lithium, in which fine-tuned regulation of glycogen synthase kinase type 3, a prime target for lithium, seems to be key. The new discoveries regarding the protective effect of lithium against AKI in rodents call for follow-up studies in humans and suggest that long-term therapy with low lithium concentrations could be beneficial in CKD.

Fibroblast Na+-Li+ countertransport rate is elevated in essential hypertension

OBJECTIVES

Elevated erythrocyte Na+- Li+ countertransport (SLC) rates are commonly found in essential hypertension. We have recently shown that human skin fibroblasts functionally express a phloretin-sensitive Na+-H+ exchange (NHE) which may also be similar to erythrocyte SLC because of amiloride-insensitivity.

DESIGN AND METHODS

We investigated whether elevations in fibroblast SLC parallel the known elevations in erythrocyte SLC and in cell NHE that characterize essential hypertension.

RESULTS

Higher fibroblast SLC rates were found among hypertensive patients (n = 23, median 48.8 nmol Li+/ mg(protein) per min) than in 19 normotensive individuals of similar age and sex (median 14.8 nmol Li+/mg(protein) per min, P= 0.0002). As expected, erythrocyte SLC was elevated in patients with hypertension (median 411 versus 329 micromol/l(cell) per h, P= 0.0273), but was not quantitatively related to fibroblast SLC. Finally, fibroblast NHE exchange activity was higher in essential hypertension (median Vmax 14.2 versus 7.6 mmol H+/l(cell) per min, P= 0.002), but was unrelated to fibroblast SLC.

CONCLUSIONS

These findings extend to human skin fibroblasts the notion of abnormal Li+ transport in essential hypertension, and appear to be in accordance with the hypothesis that fibroblast SLC may be independent of NHE. However, molecular studies will be required to understand whether distinct exchangers and/or regulation mechanisms underlie these dysregulations.

Regulation of the Na+/H+ antiporter in patients with mild chronic renal failure: effect of glucose

BACKGROUND

The aim of this study was to determine the glucose-dependent regulation of the sodium-proton-antiporter (Na+/H+ antiporter) in patients with mild chronic renal failure (CRF).

METHODS

We measured plasma glucose concentrations, plasma insulin concentrations, plasma C peptide concentrations, arterial blood pressure, cytosolic pH (pHi), cellular Na+/H+ antiporter activity, and cytosolic sodium concentration ([Na+]i) in 19 patients with CRF and 41 age-matched healthy control subjects (control) during a standardized oral glucose tolerance test. Intracellular pHi, [Na+]i, and Na+/H+ antiporter activity was measured in lymphocytes using fluorescent dye techniques.

RESULTS

Under resting conditions, the pHi was significantly lower, whereas the Na+/H+ antiporter activity was significantly higher in CRF patients compared with controls (each P < 0.0001). The oral administration of 100 g glucose significantly increased the Na+/H+ antiporter activity in CRF patients from 13.35 +/- 1.26 x 10-3 pHi/second to 16.44 +/- 1.37 x 10-3 pHi/second after one hour and to 14.06 +/- 1.36 x 10-3 pHi/second after two hours (mean +/- SEM, P = 0.008 by Friedmans's two-way analysis of variance). In controls, the administration of 100 g glucose significantly increased the Na+/H+ antiporter activity from 4.23 +/- 0.20 x 10-3 pHi/second to 6.00 +/- 0.56 x 10-3 pHi/second after one hour and to 6.65 +/- 0.64 x 10-3 pHi/second after two hours (P = 0.0003). The glucose-induced enhancement of the Na+/H+ antiporter activity was more pronounced in CRF patients compared with controls (P = 0.011). Resting [Na+]i was not significantly different between the two groups.

CONCLUSIONS

CRF patients show an intracellular acidosis leading to an increased Na+/H+ antiporter activity. In addition, high glucose levels exaggerate the differences in Na+/H+ antiporter activity already present between cells from patients with mild CRF and those from control subjects.

Can we use erythrocytes for the study of the activity of the ubiquitous Na+/H+ exchanger (NHE-1) in essential hypertension?

Both Na+/Li+ countertransport and electrochemical proton gradient (delta mu(H+))-induced Na+ and H+ fluxes are increased in erythrocytes from patients with essential hypertension. It was assumed that these abnormalities are related to ubiquitous (housekeeping) forms of the Na+/H+ exchanger (NHE-1). To examine this hypothesis, we compared kinetic and regulatory properties of erythrocyte Na+/Li+ countertransport and delta mu(H+)-induced Na+ and H+ fluxes with data obtained for cloned isoforms of the Na+/H+ exchanger. In human erythrocytes, Na+/Li+ countertransport exhibited a hyperbolic dependence on [Na+]0 with a K0.5 of approximately 30 to 40 mmol/L. The activity of this carrier was increased by two-fold in the fraction of erythrocytes enriched with the old cells, was inhibited by 0.1 mmol/L phloretin, and was insensitive to both 1 mmol/L amiloride and ATP depletion. In contrast, delta mu(H+)-induced 22Na influx was exponentially increased at [Na+]0 > 60 mmol/L, was insensitive to phloretin, was partly decreased by both 1 mmol/L amiloride and ATP depletion, and was the same in total erythrocytes and in the old cells. The values of Na+/Li+ countertransport and delta mu(H+)-induced Na+ influx in erythrocytes from different species were not correlating and their ratio in human, rat, and rabbit erythrocytes was 10:1:170 and 1:5:1 for Na+/ Li+ countertransport and delta mu(H+)-induced Na+ influx, respectively. In contrast to the majority of nonepithelial cells and cells transfected with an ubiquitous isoform of Na+/H+ exchanger, both delta mu(H+)-induced Na+ influx and Na+/Li+ countertransport in human erythrocytes were completely insensitive to ethylisopropyl amiloride (20 micromol/L) and cell shrinkage. Thus, our data strongly suggest that human erythrocyte Na+/Li+ countertransport and delta mu(H+)-induced Na+/H+ exchange are mediated by the distinct transporters. Moreover, because the properties of these erythrocyte transporters and NHE-1 are different, it complicates the use of erythrocytes for the identification of the mechanism for activating the ubiquitous form of Na+/H+ exchanger in primary hypertension.

Relevance of erythrocyte Na+/Li+ countertransport measurement in essential hypertension, hyperlipidaemia and diabetic nephropathy: a critical review

In this review the usefulness of the measurement of erythrocyte Na+/Li+ countertransport (Na+/Li+ CT) activity is evaluated. In particular, the association between enhanced erythrocyte Na+/Li+ CT activity and essential hypertension, hyperlipidaemia and diabetic nephropathy is discussed. The conclusion of this review is that elevated erythrocyte Na+/Li+ CT activity is associated with essential hypertension and hyperlipidaemia. A relationship between Na+/Li+ CT activity and diabetic nephropathy is less evident. Despite a significant link of Na+/Li+ CT activity with hypertension and hyperlipidaemia, the diagnostic significance of Na+/Li+ CT activity is low. This is due to the large overlap between the results of control subjects and patients. The factors that contribute to this broad range are discussed in detail.

Independence of dimethylamiloride-sensitive Li+ efflux pathways and Na+-Li+ countertransport in human erythrocytes

The in vivo function of the erythrocyte Na+-Li+ countertransport (SLC) is unknown. Whether SLC may reflect an operational mode of the widespread Na+-H+ exchanger (NHE) or may otherwise be expression of an independent membrane transport, remains presently unclear. We explored the presence of 5-(N,N-dimethyl)-amiloride (DMA)-sensitive Li+ pathways in human erythrocytes where the activity of the Na+ pump, Na+-K+ cotransport and anion exchange were suitably inhibited. A total of 0.02 mM DMA had no effect on SLC as expected, but gave a significant inhibition of Li+ efflux into both Na+ and Na+-free media. This DMA-sensitive Li+ pathway, but not SLC, was significantly enhanced by hyperosmolar cell shrinkage, which is a characteristic feature of NHE. In conclusion, DMA-sensitive Li+ pathways, possibly mediated by NHE, are present in erythrocytes and coexist with the DMA-insensitive, SLC. This finding supports the notion that SLC is independent of amiloride-sensitive NHE.

Sodium-dependent Cl-/HCO3- exchange in patients with chronic renal failure: correlation with renal function

To investigate the effects of uremia on cellular function the activity of the sodium-dependent chloride-bicarbonate exchanger (sodium-dependent Cl-/HCO3- exchanger) and the sodium-independent chloride-bicarbonate exchanger (sodium-independent Cl-/HCO3- exchanger) were examined in lymphocytes from 25 patients with mild chronic renal failure, 9 patients with end-stage chronic renal failure on regular hemodialysis, and from 25 age-matched healthy control subjects. Cytosolic pH (pHi) and the activity of the sodium-dependent Cl-/HCO3- exchanger and the sodium-independent Cl-/HCO3- exchanger were measured spectrophotometrically using the pH-sensitive fluorescent dye 2'7'-bis-carboxyethyl-5 [6]-carboxyfluorescein acetoxy-methylester (BCECF-AM). The activation of the sodium-dependent Cl-/HCO3- exchanger by removal of extracellular chloride was prevented in the presence of 500 micromol/liter 4,4' diisothiocyanostilbene-2,2'-disulfonic acid (DIDS) or in the absence of extracellular sodium, but was not affected by the specific inhibitor of the sodium/proton exchanger, ethyl isopropyl amiloride (EIPA). The sodium-dependent Cl-/HCO3- exchangers were significantly different in lymphocytes from healthy control subjects, patients with mild chronic renal failure, and patients with end-stage chronic renal failure (X2 = 6.43, P = 0.040 by Kruskal-Wallis-test). The sodium-dependent Cl-/HCO3- exchanger was significantly lower in patients with end-stage chronic renal failure compared to patients with mild chronic renal failure or compared to healthy control subjects (each P < 0.05). In patients with chronic renal failure a significantly negative correlation between sodium-dependent Cl-/HCO3- exchanger and the serum creatinine concentration (r = -0.507; P = 0.0022) could be observed. On the other hand, resting pHi in lymphocytes and sodium-independent Cl-/HCO3- exchanger were not significantly different in lymphocytes from healthy control subjects, patients with mild chronic renal failure or patients with end-stage chronic renal failure. The present study suggests that the activity of the sodium-dependent Cl-/HCO3- exchanger is progressively impaired in chronic renal failure.

Sodium-lithium countertransport: physiology and function

Current opinions on the relationships between erythrocyte sodium-lithium countertransport kinetics and primary hypertension, hyperlipidaemia and diabetic nephropathy are reviewed. Problems associated with the assay are analysed. Some possible mechanisms that could modify the kinetics of ion exchange are examined. The question of what catalyses sodium-lithium countertransport is discussed, but not answered. Some models are put forward showing how a study of sodium-lithium countertransport kinetics could further our understanding of important disease processes.

Sodium pump and Na+/H+ activities in uremic erythrocytes. A microcalorimetric and pH-metric study

The sodium pump and Na+/H+ antiport activities in red blood cells from uremic hemodialyzed patients were measured concomitantly. The patients selected (n = 35) were normotensive and free of intercurrent illness known to affect Na transport. The Na pump activity of intact red blood cells in suspension in their own plasma was measured by flow microcalorimetry. The Na+/H+ antiport activity of the erythrocytes from the same patients was determined by a titrimetric technique. The mean global value of the sodium pump was lower in uremics than in controls (13.3 +/- 0.6 vs. 11.3 +/- 0.8 mW/l cells, P < 0.05). The Na+/H+ antiport maximal activity was decreased in uremics (2.9 +/- 0.3 vs. 4.6 +/- 0.5 mmol H+/l cells/h, P < 0.05). Our results thus confirm that uremia per se can affect sodium transport. Moreover it has been shown that a decrease in Na+/H+ antiport activity is able to counteract an impairment of sodium pump. The decrease found in this study could thus explain, at least in part, the absence of hypertension in the patients studied despite their decreased sodium pump activity.

Protein kinase C and insulin regulation of red blood cell Na+/H+ exchange

Insulin activation of red blood cell (RBC) Na+/H+ (NHE) and Na+/Li+ (NLiE) exchanges is mimicked by okadaic acid, thus suggesting that it may change the state of phosphorylation of serine/threonine NHE residues. To investigate the role of the serine/threonine protein kinase C (PKC) in insulin regulation, we evaluated the effect of phorbol 12-myristate 13-acetate (PMA; 1 microM) and insulin on PKC activity, membrane protein phosphorylation, and the activation kinetics of both exchangers. Our studies revealed that PMA decreased cytosolic PKC activity (4.1 +/- 0.6 to 2.3 +/- 0.5 pmol x mg protein(-1) x min(-1), n = 9, P < 0.001), increased membrane PKC activity (42.3 +/- 5 to 132 +/- 12 pmol x mg protein(-1) x min(-1), n = 11, P < 0.001), and enhanced serine phosphorylation of bands 3, 4.1, and 4.9 membrane proteins. PMA markedly reduced the Michaelis constant (Km) for intracellular H+ (415 +/- 48 to 227 +/- 38 nM, n = 11, P < 0.01) but had no effect on the maximal transport rate (Vmax) of NHE and the Km for Na+ of NLiE. NHE activation and PKC activity were affected differently by insulin (100 microU/ml) and PMA. Insulin increased the Vmax of NHE and the Km for Na+ of NLiE but had no effect on the Km for intracellular H+ and membrane PKC activity. These findings lead us to conclude that in the human RBC, NHE is modulated by PKC and insulin through different biochemical mechanisms.

Increased lymphocytic Na+/H+ exchange activity after hemodialysis: evidence for an endogenous inhibitor of Na+/H+ exchange in patients with end-stage renal failure

The Na+/H+ exchange antiport activity was measured in lymphocytes from 16 patients with end-stage renal failure pre- and postdialysis. In addition the effect of the patients' plasma on lymphocytes from healthy subjects was tested. Resting pH (pHi) was not significantly different in lymphocytes pre- and postdialysis. On the other hand, the Na+/H+ exchange activity was significantly lower in lymphocytes before hemodialysis (6.22 +/- 0.73 x 10(-3) pHi/s) than after hemodialysis (9.32 +/- 1.58 x 10(-3) pHi/s; n = 16; p < 0.05). The buffer capacity was not significantly different before and after hemodialysis. The incubation of lymphocytes from healthy control subjects with plasma from patients with end-stage chronic renal failure significantly reduced the lymphocytic Na+/H+ exchange activity. The addition of ultrafiltrate also significantly reduced the Na+/H+ exchange activity in lymphocytes from healthy control subjects. The study indicates the existence of an endogenous inhibitor of the Na+/H+ exchange that is accumulated in plasma from patients with end-stage chronic renal failure.

Reconstitution of human red blood cell Na/H and Na/Na exchange transport

Na/H and Na/Na exchange transport was measured using human erythrocyte membrane proteins solubilized with octyl glucoside and reconstituted into voltage clamped soybean phospholipid membrane vesicles. The uptake of Na in exchange for either H or Na was: 1) 8 to 10 times higher in proteoliposomes that contained erythrocyte proteins than in proteoliposomes that contained heat denatured proteins or in liposomes that contained no proteins; 2) not affected by ouabain, bumetanide, or 4.4'-diisothiocyanostilbene-2-2'-disulfonic acid (DIDS); 3) inhibited by amiloride, 5-(n-ethyl-n-isopropyl)amitoride (EIPA), and 5-(n-ethyl-1-n-isobutyl)amiloride (MIA) but not phenamil; and 4) inhibited by lithium (Li) in a concentration-dependent manner. Incubation of erythrocyte proteins with a low concentration of immobilized trypsin resulted in a significant increase (52%) in Na/Na transport, but no change was seen in Na/H transport. A higher concentration of trypsin increased Na/H transport by more than 2.5 times but did not increase Na/Na transport further. Examination of these studies indicates that, as assayed in reconstituted proteoliposomes that contained erythrocyte proteins, there is a differential response between Na/H and Na/Na transport to trypsin.

Sodium-proton exchange and primary hypertension. An update

An enhancement of sodium-proton exchange in blood cells of patients with primary hypertension has been described by various investigators. The present review summarizes some of the most recent findings regarding the enhanced sodium-proton exchanger activity in primary hypertension and discusses the potential mechanisms that may contribute to or explain these findings. Novel evidence has been accumulated on the in vivo regulation of the sodium-proton exchanger in humans, and recent findings suggest that metabolic acidosis, high NaCl intake, and circulating hormones (eg, insulin) can enhance sodium-proton exchanger activity in blood cells. However, the relative roles of such exogenous factors in the stimulation of sodium-proton exchanger activity in primary hypertension remain questionable because enhanced sodium-proton exchanger activity persists in immortalized lymphoblasts from patients with primary hypertension after prolonged cell culture. Therefore, at least in a certain group of hypertensive subjects this abnormality cannot be due to metabolic or hormonal alterations of the "hypertensive" in vivo milieu but appears to be under genetic control. Available evidence strongly argues against intrinsic changes of the sodium-proton exchanger protein itself in primary hypertension, for example, a mutation in the encoding gene. Interestingly, immortalized cells from hypertensive subjects with enhanced sodium-proton exchanger activity display a distinctly enhanced proliferation pattern that appears to be independent of this ion transport. At present we speculate that enhanced sodium-proton exchanger activity and proliferation may represent indicators of a genetically fixed enhanced intracellular signal transduction in primary hypertension that may be caused by an increased activation of pertussis toxin-sensitive G proteins.

Red blood cell cation transports in uraemic anaemia: evidence for an increased K/Cl co-transport activity. Effects of dialysis and erythropoietin treatment

This study examines the role of uraemia and the effect of different dialysis treatments on red cell cation transport. We evaluated the main cation transport systems in erythrocytes of non-dialysed end-stage renal disease (ESRD) subjects, of patients undergoing haemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD), as well as the changes induced by human recombinant erythropoietin (r-HuEPO) administration. In uraemic undialysed and dialysed patients, we observed an increase in K/Cl co-transport activity and in shrinkage-induced amiloride-sensitive (HMA-sensitive) Na efflux (Na/H exchange) and a decrease in Na/K pump and Na/K/Cl co-transport activity, while Na/Li exchange was increased only in dialysed patients. In uraemic erythrocytes, we showed for the first time an increased K/Cl co-transport activity, which was cell age independent. Generally, the different method of dialysis (CAPD or HD) did not modify the cation transport abnormalities observed. During the treatment with r-HuEPO, all the systems, with the exception of the Na/K pump and Na/K/Cl co-transport, increased their activities following the increase of circulating young red cells. The changes produced under r-HuEPO administration were transient and cation transports returned to the baseline values within 100 days of treatment, indicating a primary and prominent pathogenetic role of uraemia in modulating the red cell membrane cation transport activities.

Modification of erythrocyte Na+/Li+ countertransport kinetics by two types of thiol group

Erythrocyte Na+/Li+ countertransport activity is decreased by reagents that react with thiol groups. An understanding of the role of these groups in control of Na+/Li+ countertransport may help to explain its association with disease states. The effect of thiol reactive agents on the kinetic parameters of Na+/Li+ countertransport has not previously been described. In choline medium, N-ethylmaleimide (NEM) and iodoacetamide (IAamide) cause a rapid decrease of about 40% in Km for external sodium (Km(So)) that is complete in 10 s with a much smaller change in Vmax and an increase in the Vmax/Km ratio. In Na medium, NEM and IAamide both cause a rapid decrease in Km(So) and Vmax. With NEM the partial reduction in Vmax is complete in 100s although the NEM is sufficient to reduce Vmax up to 15 min. With IAamide the decrease in Vmax is initially slower but it continues apparently towards complete inhibition. These results indicate at least two types of thiol group controlling Na+/Li+ countertransport kinetics. The type 1 thiol reaction is Na independent and causes an increase in the apparent rate constant for Na association with the unloaded carrier so that Vmax/Km rises and Km(So) decreases. The type 2 thiol reaction is facilitated by Na at the outside ion-binding site and causes a decrease in Vmax, possibly by total blockage of carriers with IAamide but by a different mechanism with NEM such as reduced turnover rate.

Expression of the human sodium/proton exchanger NHE-1 in Xenopus laevis oocytes enhances sodium/proton exchange activity and establishes sodium/lithium countertransport

We investigated whether the human sodium/proton (Na+/H+) exchanger isoform 1 (NHE-1) can mediate sodium/lithium (Na+/Li+) countertransport. Using the Xenopus laevis oocyte expression system we determined amiloride-sensitive Li+ uptake, a measure of Na+/H+ exchange, in oocytes injected with water or NHE-1 cRNA. Amiloride-sensitive Li+ uptake was three- to tenfold enhanced over control in NHE-1 cRNA-injected cells and was selectively inhibited by 0.01 microM HOE 694 [i.e. (3-methylsulphonyl-4-piperidinobenzoyl) guanidine methanesulphonate]. The endogenously present Na+/H+ exchanger was insensitive to HOE 694. After acidification of oocytes from pH 7.7 to 6.8, amiloride-sensitive Li+ uptake was four- to tenfold higher in NHE-1 cRNA-injected cells than in controls. Li+ efflux from control oocytes was independent of extracellular Na+, indicating that these cells expressed no measurable Na+/Li+ countertransport activity. In NHE-1 cRNA-injected oocytes, Li+ efflux was distinctly enhanced by extracellular Na+ ions. This Na(+)-dependent Li+ efflux was inhibited by ethylisopropylamiloride, phloretin and by cytosolic acidification. The data show that expression of the NHE-1 in X. laevis oocytes induces the expression of Na+/Li+ countertransport. The data confirm that Na+/H+ exchange and Na+/Li+ countertransport are mediated by the same transport system.

Magnesium metabolism in erythrocytes of patients with chronic renal failure and after renal transplantation

Plasma and erythrocyte Mg2+ concentrations were found to be increased in 14 haemodialysis patients with chronic renal failure and in 7 chronic renal failure patients receiving chronic ambulatory peritoneal dialysis. The rate of Na+/Mg2+ antiport was significantly higher in haemodialysis patients, but not in chronic ambulatory peritoneal dialysis patients (control: 0.15 +/- 0.02, haemodialysis: 0.46 +/- 0.08, chronic ambulatory peritoneal dialysis: 0.21 +/- 0.06; Mg2+, mmol/30 min x 1 cells). High erythrocyte Mg2+ content in chronic renal failure results from the increased plasma Mg2+, which induces elevated Mg2+ uptake during haematopoiesis. An increased rate of Na+/Mg2+ antiport, which only performs Mg2+ efflux, leads to a relatively lower erythrocyte Mg2+ content in haemodialysis patients compared with chronic ambulatory peritoneal dialysis patients. The elevated Na+/Mg2+ antiport in erythrocytes from haemodialysis patients was almost normalised after haemodialysis. Incubation of normal erythrocytes with heat-inactivated plasma from haemodialysis patients led to a doubling of Na+/Mg2+ antiport, indicating the presence of a heat-stable, dialysable plasma factor. This factor does not accumulate in chronic ambulatory peritoneal dialysis patients. After renal transplantation all changed quantities of Mg2+ metabolism returned to normal.