Direct and indirect cost of urea excretion

Amino acid metabolism in kidney health and disease

Amino acids form peptides and proteins and are therefore considered the main building blocks of life. The kidney has an important but under-appreciated role in the synthesis, degradation, filtration, reabsorption and excretion of amino acids, acting to retain useful metabolites while excreting potentially harmful and waste products from amino acid metabolism. A complex network of kidney transporters and enzymes guides these processes and moderates the competing concentrations of various metabolites and amino acid products. Kidney amino acid metabolism contributes to gluconeogenesis, nitrogen clearance, acid-base metabolism and provision of fuel for tricarboxylic acid cycle and urea cycle intermediates, and is thus a central hub for homeostasis. Conversely, kidney disease affects the levels and metabolism of a variety of amino acids. Here, we review the metabolic role of the kidney in amino acid metabolism and describe how different diseases of the kidney lead to aberrations in amino acid metabolism. Improved understanding of the metabolic and communication routes that are affected by disease could provide new mechanistic insights into the pathogenesis of kidney diseases and potentially enable targeted dietary or pharmacological interventions.

Allo-Hemodialysis, a Novel Dialytic Treatment Option for Patients with Kidney Failure: Outcomes of Mathematical Modelling, Prototyping, and Ex Vivo Testing

It has been estimated that in 2010, over two million patients with end-stage kidney disease may have faced premature death due to a lack of access to affordable renal replacement therapy, mostly dialysis. To address this shortfall in dialytic kidney replacement therapy, we propose a novel, cost-effective, and low-complexity hemodialysis method called allo-hemodialysis (alloHD). With alloHD, instead of conventional hemodialysis, the blood of a patient with kidney failure flows through the dialyzer's dialysate compartment counter-currently to the blood of a healthy subject (referred to as a "buddy") flowing through the blood compartment. Along the concentration and hydrostatic pressure gradients, uremic solutes and excess fluid are transferred from the patient to the buddy and subsequently excreted by the healthy kidneys of the buddy. We developed a mathematical model of alloHD to systematically explore dialysis adequacy in terms of weekly standard urea Kt/V. We showed that in the case of an anuric child (20 kg), four 4 h alloHD sessions are sufficient to attain a weekly standard Kt/V of >2.0. In the case of an anuric adult patient (70 kg), six 4 h alloHD sessions are necessary. As a next step, we designed and built an alloHD machine prototype that comprises off-the-shelf components. We then used this prototype to perform ex vivo experiments to investigate the transport of solutes, including urea, creatinine, and protein-bound uremic retention products, and to quantitate the accuracy and precision of the machine's ultrafiltration control. These experiments showed that alloHD performed as expected, encouraging future in vivo studies in animals with and without kidney failure.

Influence of previous plane of nutrition on molecular mechanisms regulating the expression of urea and water metabolism related genes in the rumen and kidney of finishing crossbred Angus steers

This study aimed to understand how molecular mechanisms controlling water and urea metabolism at the finishing phase can be affected by previous plane of nutrition of crossbred Angus beef steers. Twenty-four (n = 24) animals were randomly distributed into either a moderate (MP) or high plane of nutrition during the background phase for 85 d. Animals were then blocked by their previous plane and were moved onto a 105-d finishing phase in a 2 × 2 factorial arrangement. The forage-finished group received only high-quality alfalfa hay, whereas the grain-fed group received a high grain diet (80% whole corn and 20% alfalfa hay). By the end of the finishing phase, animals were harvested and tissue samples from the rumen and kidney were collected. Changes in gene expression of aquaporins (AQP)-2, -3, -4, -7, ATP1A1, ATP1B1, SGK1, CLIC1 (kidney and rumen), UT-A1 (kidney only) and UT-B (rumen only), were assayed via real-time qPCR; 18S rRNA was used as an endogenous control. One-way ANOVA followed by Tukey's post hoc analysis was conducted. When animals were from MP, forage-finishing increased the relative abundance of AQP3 (P ≤ 0.05), AQP7 (P ≤ 0.05), ATP1B1 (P ≤ 0.05), and SGK1 (P ≤ 0.05) in the kidney when compared to grain-fed animals. In the rumen, for the MP group, AQP7 was differentially expressed in both treatments at the finishing phase (P ≤ 0.01), with forage-finished steers having the highest expression of AQP7. For the MP group, UT-B had a tendency of presenting a higher expression on grain-fed animals (P = 0.075). Overall, these results suggest that previous plane can impact expression of genes associated with water and urea metabolism during the finishing phase, namely AQP3, AQP7, ATP1B1, and SGK1 in the kidney, and AQP7 and UT-B in the rumen. The greatest impact observed on gene expression changes of investigated genes at the finishing phase was reflective of animals backgrounded on the moderate previous plane.

The SLC6A18 Transporter Is Most Likely a Na-Dependent Glycine/Urea Antiporter Responsible for Urea Secretion in the Proximal Straight Tubule: Influence of This Urea Secretion on Glomerular Filtration Rate

BACKGROUND

Urea is the major end-product of protein metabolism in mammals. In carnivores and omnivores, a large load of urea is excreted daily in urine, with a concentration that is 30-100 times above that in plasma. This is important for the sake of water economy. Too little attention has been given to the existence of energy-dependent urea transport that plays an important role in this concentrating activity.

SUMMARY

This review first presents functional evidence for an energy-dependent urea secretion that occurs exclusively in the straight part of the proximal tubule (PST). Second, it proposes a candidate transmembrane transporter responsible for this urea secretion in the PST. SLC6A18 is expressed exclusively in the PST and has been identified as a glycine transporter, based on findings in SLC6A18 knockout mice. We propose that it is actually a glycine/urea antiport, secreting urea into the lumen in exchange for glycine and Na. Glycine is most likely recycled back into the cell via a transporter located in the brush border. Urea secretion in the PST modifies the composition of the tubular fluid in the thick ascending limb and, thus, contributes, indirectly, to influence the "signal" at the macula densa that plays a crucial role in the regulation of the glomerular filtration rate (GFR) by the tubulo-glomerular feedback.

KEY MESSAGES

Taking into account this secondary active secretion of urea in the mammalian kidney provides a new understanding of the influence of protein intake on GFR, of the regulation of urea excretion, and of the urine-concentrating mechanism.

Postprandial metabolism and gut permeability in calves fed milk replacer with different macronutrient profiles or a whole milk powder

Significant differences exist in the composition of current milk replacers (MR) and bovine whole milk. This study investigated how the macronutrient profile of 3 different MR formulations containing varying amounts of fat, lactose, and protein, and a whole milk powder (WP), affect postprandial metabolism and gut permeability in male Holstein calves. Sixty-four calves (45.4 ± 4.19 kg [mean ± SD] and 1.8 ± 0.62 d of age) were blocked in order of arrival to the facility and within each block, calves were randomly assigned to 1 of 4 treatments. Treatments included a high-fat MR (HF: 25.0% dry matter [DM] fat, 22.5% protein, 38.6% lactose; n = 14), a high-lactose MR (HL: 44.6% lactose, 22.5% protein, 18.0% fat; n = 17), a high-protein MR (HP: 26.0% protein, 18.0% fat, 41.5% lactose; n = 17), and WP (26.0% fat, 24.5% protein, 38.0% lactose; n = 16). Calves were fed 3.0 L (135 g/L) 3 times daily at 0600, 1200, and 1800 h with a teat bucket. Milk intake was recorded daily for the first 28 d after arrival, and blood sampling and body weight measurements were performed at arrival and on d 7, 14, 21, and 27. Gut permeability was estimated from fractional urinary excretion of indigestible markers (Cr-EDTA, lactulose, and d-mannitol) administered as a single dose on d 21 instead of the morning milk meal. Digestibility was determined simultaneously from a total collection of feces over 24 h. Postprandial dynamics were measured on d 28 by sequential blood sampling over 7.5 h. Dry matter intake of MR over 28 d was slightly greater in calves fed HL and HP than in WP. Recovery of Cr-EDTA and d-mannitol over a 24-h urine collection was greater in calves fed WP and HP than HL calves. Apparent total-tract digestibility of crude ash, protein, and fat did not differ among treatments; however, DM digestibility was lower in calves fed WP than in other treatment groups. In addition, abomasal emptying, as indicated by the area under the curve (AUC) for acetaminophen, was slower in calves fed WP than in calves fed HF and HL. The AUC for postprandial plasma glucose was lower in calves fed HL than WP and HF and lower in calves fed HP than WP. The AUC for postprandial serum insulin was greater in calves fed HP than WP and HF, whereas calves fed HL did not differ from the other treatments. Postprandial triglycerides were greater in calves fed WP, and postprandial adiponectin was higher in calves fed HL than other treatments. The high content of lactose and protein in MR had a major effect on postprandial metabolism. This raises the possibility of optimizing MR formulations to maintain metabolic homeostasis and influence development.

The urine-to-plasma urea concentration ratio is associated with eGFR and eGFR decline over time in a population cohort

BACKGROUND

Evaluation of renal function and of factors associated with its decline are important public health issues. Besides markers of glomerular function [e.g. glomerular filtration rate (GFR)], those of tubular functions are rarely evaluated. Urea, the most abundant urinary solute, is markedly concentrated in urine when compared with plasma. We explored the urine-to-plasma ratio of urea concentrations (U/P urea ratio) as a marker of tubular functions.

METHODS

We evaluated the relationship of the U/P urea ratio with eGFR at baseline in 1043 participants (48 ± 17 years) from the Swiss Kidney Project on Genes in Hypertension (SKIPOGH) population-based cohort, using mixed regression. In 898 participants, we assessed the relation between U/P urea ratio and renal function decline between two study waves 3 years apart. We studied U/P ratios for osmolarity, Na, K and uric acid for comparison.

RESULTS

In a transversal study at baseline, estimated GFR (eGFR) was positively associated with U/P-urea ratio [βscaled = 0.08, 95% CI (0.04; 0.13)] but not with the U/P ratio of osmolarity. Considering separately participants with renal function >90 or ≤90 mL/min × 1.73 m2, this association was observed only in those with reduced renal function. In the longitudinal study, eGFR declined at a mean rate of 1.2 mL/min per year. A significant association was observed between baseline U/P urea ratio and eGFR decline [βscaled = 0.08, 95% CI (0.01; 0.15)]. A lower baseline U/P urea ratio was associated with a greater eGFR decline.

CONCLUSION

This study provides evidence that the U/P urea ratio is an early marker of kidney function decline in the general adult population. Urea is easy to measure with well-standardized techniques and at low cost. Thus, the U/P urea ratio could become an easily available tubular marker for evaluating renal function decline.

Protein - a scoping review for Nordic Nutrition Recommendations 2023

Proteins are needed for providing essential amino acids, nitrogen, and fuel for the body's needs in all age groups. Proteins are especially required during active growth in pregnancy, lactation, childhood, and tissue growth in general. An adequate protein intake is needed in old adults to avoid premature muscle loss. According to the current dietary surveys, protein intake in the Nordic and Baltic countries varies from 15 to 19% of the total energy intake in adults. Comprehensive data regarding children and older adults are lacking. No good measure for protein status exists, and the estimation of physiological requirements is based on N-balance studies having some weaknesses. Protein quality is assessed by considering the protein digestibility of individual indispensable amino acids and their utilization (bioavailability), which is affected by food antinutrients and processing. The evidence regarding the association of protein intake per se with health outcomes is limited or suggestive. It is difficult to separate from the effect of other nutrients or ingredients in protein-rich foods. Proteins are widespread in foods, deriving from both animal and plant sources. Animal-sourced protein production puts more strain on the environment than plant-sourced proteins and contributes significantly to greenhouse gas emissions, thereby enhancing climate change. In Nordic and Baltic countries, consumption of animal-sourced proteins is relatively high. A shift toward more plant-based protein diets would be advisable for promoting a healthy and sustainable diet.

Association of the Urine-to-Plasma Urea Ratio With CKD Progression

RATIONALE & OBJECTIVES

The urine-to-plasma (U/P) ratio of urea is correlated with urine-concentrating capacity and associated with progression of autosomal dominant polycystic kidney disease. As a proposed biomarker of tubular function, we hypothesized that the U/P urea ratio would also be associated with progression of more common forms of chronic kidney disease (CKD).

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

3,723 adults in the United States with estimated glomerular filtration rate (eGFR) of 20-70 mL/min/1.73 m², enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study.

EXPOSURE

U/P urea ratio, calculated from 24-hour urine collections and plasma samples at baseline.

OUTCOME

Associations of U/P urea ratio with eGFR slope, initiation of kidney replacement therapy (KRT), and CKD progression, defined as 50% decline in eGFR or incident KRT.

ANALYTICAL APPROACH

Multivariable linear mixed-effects models tested associations with eGFR slope. Cox proportional hazards models tested associations with dichotomous CKD outcomes.

RESULTS

The median U/P urea ratio was 14.8 (IQR, 9.5-22.2). Compared with participants in the highest U/P urea ratio quintile, those in the lowest quintile had a greater eGFR decline by 1.06 mL/min/1.73 m² per year (P < 0.001) over 7.0 (IQR, 3.0-11.0) years of follow-up observation. Each 1-SD lower natural log-transformed U/P urea ratio was independently associated with CKD progression (HR, 1.22 [95% CI, 1.12-1.33]) and incident KRT (HR, 1.22 [95% CI, 1.10-1.33]). Associations differed by baseline eGFR (P interaction = 0.009). Among those with an eGFR ≥30 mL/min/1.73 m², each 1-SD lower in ln(U/P urea ratio) was independently associated with CKD progression (HR, 1.30 [95% CI, 1.18-1.45]), but this was not significant among those with eGFR <30 mL/min/1.73 m² (HR, 1.00 [95% CI, 0.84-1.20]).

LIMITATIONS

Possibility of residual confounding. Single baseline 24-hour urine collection for U/P urea ratio.

CONCLUSIONS

In a large and diverse cohort of patients with common forms of CKD, U/P urea was independently associated with disease progression and incident kidney failure. Associations were not significant among those with advanced CKD at baseline.

Vaptans or voluntary increased hydration to protect the kidney: how do they compare?

The adverse effects of vasopressin (AVP) in diverse forms of chronic kidney disease have been well described. They depend on the antidiuretic action of AVP mediated by V2 receptors (V2R). Tolvaptan, a selective V2R antagonist, is now largely used for the treatment of patients with autosomal dominant polycystic kidney disease. Another way to reduce the adverse effects of AVP is to reduce endogenous AVP secretion by a voluntary increase in fluid intake. These two approaches differ in several ways, including the level of thirst and AVP. With voluntary increased drinking, plasma osmolality will decline and so will AVP secretion. Thus, not only will V2R-mediated effects be reduced, but also those mediated by V1a and V1b receptors (V1aR and V1bR). In contrast, selective V2R antagonism will induce a loss of fluid that will stimulate AVP secretion and thus increase AVP's influence on V1a and V1b receptors. V1aR is expressed in the luminal side of the collecting duct (CD) and in inner medullary interstitial cells, and their activation induces the production of prostaglandins, mostly prostaglandin E2 (PGE2). Intrarenal PGE2 has been shown to reduce sodium and water reabsorption in the CD and increase blood flow in the renal medulla, both effects contributing to increase sodium and water excretion and reduce urine-concentrating activity. Conversely, non-steroidal anti-inflammatory drugs have been shown to induce significant water and sodium retention and potentiate the antidiuretic effects of AVP. Thus, during V2R antagonism, V1aR-mediated actions may be responsible for part of the diuresis observed with this drug. These V1aR-dependent effects do not take place with a voluntary increase in fluid intake. In summary, while both strategies may have beneficial effects, the information reviewed here leads us to assume that pharmacological V2R antagonism, with resulting stimulation of V1aR and increased PGE2 production, may provide greater benefit than voluntary high water intake. The influence of tolvaptan on the PGE2 excretion rate and the possibility to use somewhat lower tolvaptan doses than presently prescribed remain to be evaluated.

Noninvasively differentiating acute and chronic nephropathies via multiparametric urea-CEST, nuclear Overhauser enhancement-CEST, and quantitative magnetization transfer MRI

PURPOSE

Standardized blood tests often lack adequate sensitivity and specificity to capture the gradual progression of renal injuries. We suggest a multiparametric molecular MRI approach as a noninvasive tool for monitoring renal function loss and distinguishing different types of renal injuries.

METHODS

CEST and quantitative magnetization transfer (qMT) imaging were performed on cisplatin (n = 16) and aristolochic acid (AA)-induced nephropathy (n = 22) mouse models at 7T with an infusion of either saline or urea. Seven-pool Lorentzian fitting was applied for the analysis of CEST Z-spectra, and the T1 -corrected CEST contrast apparent exchange-dependent relaxation (AREX) from urea (+1 ppm) and two nuclear Overhauser enhancement (NOE) pools (-1.6 and -3.5 ppm) were measured. Similarly, qMT spectra were fitted into two-pool Ramani equation and the relative semi-solid macromolecular pool-size ratio was measured. Histology of mouse kidneys was performed to validate the MR findings.

RESULTS

AA model showed disrupted spatial gradients of urea in the kidney and significantly decreased NOE CEST and qMT contrast. The cisplatin model showed slightly decreased qMT contrast only. The orrelation of MR parameters to histological features showed that NOE CEST and qMT imaging are sensitive to both acute and chronic injuries, whereas urea CEST shows a significant correlation only to acute injuries.

CONCLUSION

These results indicate that our multiparametric approach allows comprehensive and totally noninvasive monitoring of renal function and histological changes for distinguishing different nephropathies.

Urinalysis of individuals with renal hyperfiltration using ATR-FTIR spectroscopy

Abnormal increased glomerular filtration rate (GFR), otherwise known as renal hyperfiltration (RHf), is associated with an increased risk of chronic kidney disease and cardiovascular mortality. Although it is not considered as a disease alone in medicine today, early detection of RHf is essential to reducing risk in a timely manner. However, detecting RHf is a challenge since it does not have a practical biochemical marker that can be followed or quantified. In this study, we tested the ability of ATR-FTIR spectroscopy to distinguish 17 individuals with RHf (hyperfiltraters; RHf (+)), from 20 who have normal GFR (normofiltraters; RHf(-)), using urine samples. Spectra collected from hyperfiltraters were significantly different from the control group at positions 1621, 1390, 1346, 933 and 783/cm. Intensity changes at these positions could be followed directly from the absorbance spectra without the need for pre-processing. They were tentatively attributed to urea, citrate, creatinine, phosphate groups, and uric acid, respectively. Using principal component analysis (PCA), major peaks of the second derivative forms for the classification of two groups were determined. Peaks at 1540, 1492, 1390, 1200, 1000 and 840/cm were significantly different between the two groups. Statistical analysis showed that the spectra of normofiltraters are similar; however, those of hyperfiltraters show diversity at multiple positions that can be observed both from the absorbance spectra and the second derivative profiles. This observation implies that RHf can simultaneously affect the excretion of many substances, and that a spectroscopic analysis of urine can be used as a rapid and non-invasive pre-screening tool.

Urine volume as an estimator of residual renal clearance and urinary removal of solutes in patients undergoing peritoneal dialysis

In non-anuric patients undergoing peritoneal dialysis (PD), residual kidney function (RKF) is a main contributor to fluid and solute removal and an independent predictor of survival. We investigated if urine volume could be used to estimate renal clearances and removal of urea, creatinine, and phosphorus in PD patients. The observational, cross-sectional study included 93 non-anuric prevalent PD patients undergoing continuous ambulatory PD (CAPD; n = 34) or automated PD (APD; n = 59). Concentrations of urea, creatinine and phosphorus in serum and in 24-h collections of urine volume were measured to calculate weekly residual renal clearance (L/week) and removed solute mass (g/week). Median [interquartile range], 24-h urine output was 560 [330-950] mL and measured GFR (the mean of creatinine and urea clearances) was 3.24 [1.47-5.67] mL/min. For urea, creatinine and phosphorus, residual renal clearance was 20.60 [11.49-35.79], 43.02 [19.13-75.48] and 17.50 [8.34-33.58] L/week, respectively, with no significant differences between CAPD and APD. Urine volume correlated positively with removed solute masses (rho = 0.82, 0.67 and 0.74) and with weekly residual renal clearances (rho = 0.77, 0.62 and 0.72 for urea, creatinine, and phosphorus, respectively, all p < 0.001). Residual renal clearances and urinary mass removal rates for urea, creatinine, and phosphorus correlate strongly with 24-h urine volume suggesting that urine volume could serve as an estimator of typical values of residual solute removal indices in PD patients.

The dual therapeutic effect of metformin nuclei‐based drugs modified with one of Tulbaghia violacea extract compounds

Novel Schiff base was synthesized from the condensation reaction of metformin with [4‐(Diethylamino) benzaldehyde (NBM). Different metal complexes were prepared using Pd (II), Pt (II), Cu (II), and V (IV) metal ions. All complexes showed the nonelectrolytic behavior. So, the expected molecular formulas for complexes were [Pd (NBM)Cl2], [Pt (NBM)Cl2], [Cu (NBM)2Cl2] and [VO (NBM)2]. The cytotoxicity of (NBM) Schiff base and its metal complexes on human cancer cell line, MCF‐7, was investigated. V (IV) and Cu (II) complexes showed potential blood glucose lowering effect higher than the commercial metformin drug. VO (II) complex has superior antioxidant activity more than the other synthesized compounds and the standard ascorbic acid. Molecular docking investigation proved the presence of interesting interactions between all synthesized compounds with the active site amino acids of EGFR tyrosine kinase (anticancer activity). The molecular docking of metal complexes has observed effective inhibition for the specific mTOR protein that is expected to aid the growth of the COVID‐19 virus.

Kidney disease risk factors do not explain impacts of low dietary protein on kidney function and structure

The kidneys balance many byproducts of the metabolism of dietary components. Previous studies examining dietary effects on kidney health are generally of short duration and manipulate a single macronutrient. Here, kidney function and structure were examined in C57BL/6J mice randomized to consume one of a spectrum of macronutrient combinations (protein [5%–60%], carbohydrate [20%–75%], and fat [20%–75%]) from weaning to late-middle age (15 months). Individual and interactive impacts of macronutrients on kidney health were modeled. Dietary protein had the greatest influence on kidney function, where chronic low protein intake decreased glomerular filtration rates and kidney mass, whereas it increased kidney immune infiltration and structural injury. Kidney outcomes did not align with cardiometabolic risk factors including glucose intolerance, overweight/obesity, dyslipidemia, and hypertension in mice with chronic low protein consumption. This study highlights that protein intake over a lifespan is an important determinant of kidney function independent of cardiometabolic changes.

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Chronic high macronutrient intake from any source increases kidney function (GFR)

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Low protein intake led to greater kidney tubular structural injury and inflammation

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Lower protein intake decreased kidney mass and glomerular filtration capacity

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Kidney outcomes did not align with longevity or cardiometabolic outcomes

Whey protein supplementation and its potentially adverse effects on health: a systematic review

Whey protein comprises soluble whey proteins and its benefits are well described in the literature. However, there are not many studies investigating the potential adverse effect of a diet with indiscriminate use of this supplement. The aim of this study was to perform a systematic review of papers that addressed this theme. A search was conducted in Medline, LILACS, TOXNET, Web of science, and Scopus electronic databases. In the end, 11 documents comprised this review. The majority of the papers associated the damaging effect with the chronic and abusive use of whey protein, with the kidneys and liver being the main organs affected. The other studies related whey protein to aggravation of aggression, presence of acne, and modification of the microbiota. Therefore, excessive consumption over a long period of protein supplementation may have some adverse effects on the body, which is aggravated when associated with sedentary lifestyle. PROSPERO registration no.: CRD42020140466. Novelty: A systematic review of experimental and randomized studies about the use of whey proteins supplements and its impact on physical health. Analysis revealed that chronic and without professional guidance use of whey protein supplementation may cause some adverse effects specially on kidney and liver function. Presented data support a need for future studies co-relating the use of different types of whey protein with and without exercise to better see the impact on human physical health.

Protein Status Modulates an Appetite for Protein To Maintain a Balanced Nutritional State-A Perspective View

Protein sufficiency is tightly controlled through different sensing and signaling processes that modulate and adapt protein and energy metabolism and feeding behavior to reach and maintain a well-balanced protein status. High-protein diets, often discussed in the context of body weight management, usually activate anorexigenic pathways, leading to higher satiety, decreased food and energy intake, and decreased body weight and adiposity. Diets marginally low in protein (3-8% energy) or marginally deficient in some indispensable amino acid more often activate orexigenic pathways, with higher appetite and a specific appetite for protein, a response that leads to an increase in protein intake to partially compensate for the deficit in protein and amino acid. Diets severely deficient in protein (2-3% energy as protein) usually depress food intake and induce lower weight and lower fat mass and lean tissues that characterize a status of protein deficiency. The control of protein sufficiency involves various peripheral and central signals, including modulation of both metabolic pathways at the periphery as well as central pathways of the control of food and protein intake, including a reward-driven specific sensitivity to the protein content of foods.

Plasma copeptin as a predictor of kidney disease

Background

Plasma copeptin, a marker of vasopressin, is associated with renal function decline in the general population. Our aim was to study the links between elevated copeptin and future risk of kidney disease.

Methods

Copeptin was measured in a sample of the Malmö Preventive Project (MPP) Reinvestigation (n = 5158) and in the Malmö Diet and Cancer Cardiovascular Cohort (MDC-CC) (n = 5162). According to national registers, 89 subjects in MPP and 180 in MDC-CC developed chronic kidney disease (CKD) during follow-up (8.7 and 19.6 years, respectively).

Results

After multivariate adjustment (gender, age, body mass index, smoking status, estimated glomerular filtration rate, prevalent diabetes, systolic blood pressure and prevalent antihypertensive treatment), copeptin (beta-coefficient per 1 standard deviation increment of ln copeptin) was independently associated with increased risk of CKD during follow-up in both cohorts (MPP: (HR) 1.46, 95% confidence interval (CI) 1.18–1.80, P < 0.001; MDC-CC: HR 1.25, 95% CI 1.02–1.54, P = 0.03) among subjects free from prevalent kidney disease at baseline. Furthermore, in MPP, elevated copeptin predicted a specified diagnosis of kidney disease other than CKD (HR 1.31, 95% CI 1.08–1.59, P = 0.006) after multivariate adjustment. In a corresponding analysis in MDC-CC, copeptin was associated with a 10% increased risk, which, however, was non-significant (P = 0.25). A meta-analysis of the MPP and MDC-CC data showed significant association between elevated copeptin and a specified diagnosis of kidney disease other than CKD (HR 1.18, 95% CI 1.05–1.34, P = 0.008).

Conclusion

An increased level of copeptin independently predicts development of both CKD and other specified kidney diseases, suggesting that copeptin can be used to identify individuals at risk for kidney disease development.

Noninvasive imaging of renal urea handling by CEST-MRI

PURPOSE

Renal function is characterized by concentration of urea for removal in urine. We tested urea as a CEST-MRI contrast agent for measurement of the concentrating capacity of distinct renal anatomical regions.

METHODS

The CEST contrast of urea was examined using phantoms with different concentrations and pH levels. Ten C57BL/6J mice were scanned twice at 7 T, once following intraperitoneal injection of 2M 150 µL urea and separately following an identical volume of saline. Kidneys were segmented into regions encompassing the cortex, outer medulla, and inner medulla and papilla to monitor spatially varying urea concentration. Z-spectra were acquired before and 20 minutes after injection, with dynamic scanning of urea handling performed in between via serial acquisition of CEST images acquired following saturation at +1 ppm.

RESULTS

Phantom experiments revealed concentration and pH-dependent CEST contrast of urea that was both acid- and base-catalyzed. Z-spectra acquired before injection showed significantly higher CEST contrast in the inner medulla and papilla (2.3% ± 1.9%) compared with the cortex (0.15% ± 0.75%, P = .011) and outer medulla (0.12% ± 0.58%, P = .008). Urea infusion increased CEST contrast in the inner medulla and papilla by 2.1% ± 1.9% (absolute), whereas saline infusion decreased CEST contrast by -0.5% ± 2.0% (absolute, P = .028 versus urea). Dynamic scanning revealed that thermal drift and diuretic status are confounding factors.

CONCLUSION

Urea CEST has a potential of monitoring renal function by capturing the spatially varying urea concentrating ability of the kidneys.

Effects of a high protein diet and liver disease in an in silico model of human ammonia metabolism

BACKGROUND

After proteolysis, the majority of released amino acids from dietary protein are transported to the liver for gluconeogenesis or to peripheral tissues where they are used for protein synthesis and eventually catabolized, producing ammonia as a byproduct. High ammonia levels in the brain are a major contributor to the decreased neural function that occurs in several pathological conditions such as hepatic encephalopathy when liver urea cycle function is compromised. Therefore, it is important to gain a deeper understanding of human ammonia metabolism. The objective of this study was to predict changes in blood ammonia levels resulting from alterations in dietary protein intake, from liver disease, or from partial loss of urea cycle function.

METHODS

A simple mathematical model was created using MATLAB SimBiology and data from published studies. Simulations were performed and results analyzed to determine steady state changes in ammonia levels resulting from varying dietary protein intake and varying liver enzyme activity levels to simulate liver disease. As a toxicity reference, viability was measured in SH-SY5Y neuroblastoma cells following differentiation and ammonium chloride treatment.

RESULTS

Results from control simulations yielded steady state blood ammonia levels within normal physiological limits. Increasing dietary protein intake by 72% resulted in a 59% increase in blood ammonia levels. Simulations of liver cirrhosis increased blood ammonia levels by 41 to 130% depending upon the level of dietary protein intake. Simulations of heterozygous individuals carrying a loss of function allele of the urea cycle carbamoyl phosphate synthetase I (CPS1) gene resulted in more than a tripling of blood ammonia levels (from roughly 18 to 60 μM depending on dietary protein intake). The viability of differentiated SH-SY5Y cells was decreased by 14% by the addition of a slightly higher amount of ammonium chloride (90 μM).

CONCLUSIONS

Data from the model suggest decreasing protein consumption may be one simple strategy to decrease blood ammonia levels and minimize the risk of developing hepatic encephalopathy for many liver disease patients. In addition, the model suggests subjects who are known carriers of disease-causing CPS1 alleles may benefit from monitoring blood ammonia levels and limiting the level of protein intake if ammonia levels are high.

Glucagon revisited: Coordinated actions on the liver and kidney

Glucagon secretion is stimulated by a low plasma glucose concentration. By activating glycogenolysis and gluconeogenesis in the liver, glucagon contributes to maintain a normal glycemia. Glucagon secretion is also stimulated by the intake of proteins, and glucagon contributes to amino acid metabolism and nitrogen excretion. Amino acids are used for gluconeogenesis and ureagenesis, two metabolic pathways that are closely associated. Intriguingly, cyclic AMP, the second messenger of glucagon action in the liver, is released into the bloodstream becoming an extracellular messenger. These effects depend not only on glucagon itself but on the actual glucagon/insulin ratio because insulin counteracts glucagon action on the liver. This review revisits the role of glucagon in nitrogen metabolism and in disposal of nitrogen wastes. This role involves coordinated actions of glucagon on the liver and kidney. Glucagon influences the transport of fluid and solutes in the distal tubule and collecting duct, and extracellular cAMP influences proximal tubule reabsorption. These combined effects increase the fractional excretion of urea, sodium, potassium and phosphates. Moreover, the simultaneous actions of glucagon and extracellular cAMP are responsible, at least in part, for the protein-induced rise in glomerular filtration rate that contributes to a more efficient excretion of protein-derived end products.

Long-term dietary restriction up-regulates activity and expression of renal arginase II in aging mice

Arginase II is a mitochondrial enzyme that catalyses the hydrolysis of L-arginine into urea and ornithine. It is present in other extra-hepatic tissues that lack urea cycle. Therefore, it is plausible that arginase II has a physiological role other than urea cycle which includes polyamine, proline, glutamate synthesis and regulation of nitric oxide production. The high expression of arginase II in kidney, among extrahepatic tissues, might have an important role associated with kidney functions. The present study is aimed to determine the age-associated alteration in the activity and expression of arginase II in the kidney of mice of different ages. The effect of dietary restriction to modulate the agedependent changes of arginase II was also studied. Results showed that renal arginase II activity declines significantly with the progression of age (p less than 0.01 and p less than 0.001 in 6- and 18-month-old mice, respectively as compared to 2-month old mice) and is due to the reduction in its protein as well as the mRNA level (p less than 0.001 in both 6- and 18-month-old mice as compared to 2-month-old mice). Long-term dietary restriction for three months has significantly up-regulated arginase II activity and expression level in both 2- and 18-month-old mice (p less than 0.01 and p less than 0.001, respectively as compared to AL group). These findings clearly indicate that the reducing level of arginase II during aging might have an impact on the declining renal functions. This age-dependent down-regulation of arginase II in the kidney can be attenuated by dietary restriction which may help in the maintenance of such functions.

Higher Protein Intake Is Not Associated with Decreased Kidney Function in Pre-Diabetic Older Adults Following a One-Year Intervention-A Preview Sub-Study

Concerns about detrimental renal effects of a high-protein intake have been raised due to an induced glomerular hyperfiltration, since this may accelerate the progression of kidney disease. The aim of this sub-study was to assess the effect of a higher intake of protein on kidney function in pre-diabetic men and women, aged 55 years and older. Analyses were based on baseline and one-year data in a sub-group of 310 participants included in the PREVIEW project (PREVention of diabetes through lifestyle Intervention and population studies in Europe and around the World). Protein intake was estimated from four-day dietary records and 24-hour urinary urea excretion. We used linear regression to assess the association between protein intake after one year of intervention and kidney function markers: creatinine clearance, estimated glomerular filtration rate (eGFR), urinary albumin/creatinine ratio (ACR), urinary urea/creatinine ratio (UCR), serum creatinine, and serum urea before and after adjustments for potential confounders. A higher protein intake was associated with a significant increase in UCR (p = 0.03) and serum urea (p = 0.05) after one year. There were no associations between increased protein intake and creatinine clearance, eGFR, ACR, or serum creatinine. We found no indication of impaired kidney function after one year with a higher protein intake in pre-diabetic older adults.

A Protein Diet Score, Including Plant and Animal Protein, Investigating the Association with HbA1c and eGFR-The PREVIEW Project

Higher-protein diets have been advocated for body-weight regulation for the past few decades. However, the potential health risks of these diets are still uncertain. We aimed to develop a protein score based on the quantity and source of protein, and to examine the association of the score with glycated haemoglobin (HbA1c) and estimated glomerular filtration rate (eGFR). Analyses were based on three population studies included in the PREVIEW project (PREVention of diabetes through lifestyle Intervention and population studies in Europe and around the World): NQplus, Lifelines, and the Young Finns Study. Cross-sectional data from food-frequency questionnaires (n = 76,777 subjects) were used to develop a protein score consisting of two components: 1) percentage of energy from total protein, and 2) plant to animal protein ratio. An inverse association between protein score and HbA1c (slope −0.02 ± 0.01 mmol/mol, p < 0.001) was seen in Lifelines. We found a positive association between the protein score and eGFR in Lifelines (slope 0.17 ± 0.02 mL/min/1.73 m², p < 0.0001). Protein scoring might be a useful tool to assess both the effect of quantity and source of protein on health parameters. Further studies are needed to validate this newly developed protein score.

Potential of Mean Force Calculations of Solute Permeation Across UT-B and AQP1: A Comparison between Molecular Dynamics and 3D-RISM

Membrane channels facilitate the efficient and selective flux of various solutes across biological membranes. A common approach to investigate the selectivity of a channel has been the calculation of potentials of mean force (PMFs) for solute permeation across the pore. PMFs have been frequently computed from molecular dynamics (MD) simulations, yet the three-dimensional reference interaction site model (3D-RISM) has been suggested as a computationally efficient alternative to MD. Whether the two methods yield comparable PMFs for solute permeation has remained unclear. In this study, we calculated potentials of mean force for water, ammonia, urea, molecular oxygen, and methanol across the urea transporter B (UT-B) and aquaporin-1 (AQP1), using 3D-RISM, as well as using MD simulations and umbrella sampling. To allow direct comparison between the PMFs from 3D-RISM and MD, we ensure that all PMFs refer to a well-defined reference area in the bulk or, equivalently, to a well-defined density of channels in the membrane. For PMFs of water permeation, we found reasonable agreement between the two methods, with differences of ≲3 kJ mol-1. In contrast, we found stark discrepancies for the PMFs for all other solutes. Additional calculations confirm that discrepancies between MD and 3D-RISM are not explained by the choice for the closure relation, the definition the reaction coordinate (center of mass-based versus atomic site-based), details of the molecule force field, or fluctuations of the protein. Comparison of the PMFs suggests that 3D-RISM may underestimate effects from hydrophobic solute-channel interactions, thereby, for instance, missing the urea binding sites in UT-B. Furthermore, we speculate that the orientational averages inherent to 3D-RISM might lead to discrepancies in the narrow channel lumen. These findings suggest that current 3D-RISM solvers provide reasonable estimates for the PMF for water permeation, but that they are not suitable to study the selectivity of membrane channels with respect to uncharged nonwater solutes.

Increased Hydration Can Be Associated with Weight Loss

This mini-review develops the hypothesis that increased hydration leads to body weight loss, mainly through a decrease in feeding, and a loss of fat, through increased lipolysis. The publications cited come from animal, mainly rodent, studies where manipulations of the central and/or the peripheral renin–angiotensin system lead to an increased drinking response and a decrease in body weight. This hypothesis derives from a broader association between chronic hypohydration (extracellular dehydration) and raised levels of the hormone angiotensin II (AngII) associated with many chronic diseases, such as obesity, diabetes, cancer, and cardiovascular disease. Proposed mechanisms to explain these effects involve an increase in metabolism due to hydration expanding cell volume. The results of these animal studies often can be applied to the humans. Human studies are consistent with this hypothesis for weight loss and for reducing the risk factors in the development of obesity and type 2 diabetes.

Branched-Chain Amino Acid Supplementation in Combination with Voluntary Running Improves Body Composition in Female C57BL/6 Mice

Exercise is an inexpensive intervention that may be used to reduce obesity and its consequences. In addition, many individuals who regularly exercise utilize dietary supplements to enhance their exercise routine and to accelerate fat loss or increase lean mass. Branched-chain amino acids (BCAAs) are a popular supplement and have been shown to produce a number of beneficial effects in rodent models and humans. Therefore, we hypothesized that BCAA supplementation would protect against high fat diet (HFD)-induced glucose intolerance and obesity in mice with and without access to exercise. We subjected 80 female C57BL/6 mice to a paradigm of HFD feeding, exercise in the form of voluntary wheel running, and BCAA supplementation in the drinking water for 16 weeks (n = 10 per group). Body weight was monitored weekly, while food and water consumption were recorded twice weekly. During the 5th, 10th, and 15th weeks of treatment, glucose tolerance and body composition were analyzed. Exercise significantly improved glucose tolerance in both control-fed and HFD-fed mice. BCAA supplementation, however, did not significantly alter glucose tolerance in any treatment group. While BCAA supplements did not improve lean to fat mass ratio in sedentary mice, it significantly augmented the effects of exercise on this parameter.

Protein- and diabetes-induced glomerular hyperfiltration: role of glucagon, vasopressin, and urea

A single protein-rich meal (or an infusion of amino acids) is known to increase the glomerular filtration rate (GFR) for a few hours, a phenomenon known as “hyperfiltration.” It is important to understand the factors that initiate this upregulation because it becomes maladaptive in the long term. Several mediators and paracrine factors have been shown to participate in this upregulation, but they are not directly triggered by protein intake. Here, we explain how a rise in glucagon and in vasopressin secretion, directly induced by protein ingestion, might be the initial factors triggering the hepatic and renal events leading to an increase in the GFR. Their effects include metabolic actions in the liver and stimulation of sodium chloride reabsorption in the thick ascending limb. Glucagon is not only a glucoregulatory hormone. It is also important for the excretion of nitrogen end products by stimulating both urea synthesis in the liver (along with gluconeogenesis from amino acids) and urea excretion by the kidney. Vasopressin allows the concentration of nitrogenous end products (urea, ammonia, etc.) and other protein-associated wastes in a hyperosmotic urine, thus allowing a very significant water economy characteristic of all terrestrial mammals. No hyperfiltration occurs in the absence of one or the other hormone. Experimental results suggest that the combined actions of these two hormones, along with the complex intrarenal handling of urea, lead to alter the composition of the tubular fluid at the macula densa and to reduce the intensity of the signal activating the tubuloglomerular feedback control of GFR, thus allowing GFR to raise. Altogether, glucagon, vasopressin, and urea contribute to set up the best compromise between efficient urea excretion and water economy.

Urine Osmolarity and Risk of Dialysis Initiation in a CKD Cohort

Background: Several experimental studies in rats and a few association studies in humans suggest that the antidiuretic action of vasopressin may accelerate the progression of chronic kidney disease. We undertook a retrospective analysis in a monocentric cohort of 273 patients with chronic kidney disease stages 1-4, focusing on a strong variable of interest, urinary osmolarity, and a strong endpoint, dialysis initiation. Data was analyzed in a multivariate proportional sub-distribution hazards model for competing risk data with appropriate co-variates. Main Results: Over a median follow-up period of 92 months, dialysis was initiated in 105 patients. After adjustments for baseline creatinine clearance, and other confounding factors, a higher risk for initiation of dialysis was found in patients with higher urinary osmolarity. After 72 months, the estimated adjusted cumulative incidence probability for dialysis initiation was 15, 24, and 34% in patients with baseline urinary osmolarity of 315, 510, and 775 mosm/l, respectively (p = 0.033). Key Messages: In this retrospective, longitudinal study, a higher baseline urinary osmolarity was strongly associated with a higher risk of end-stage renal disease (after appropriate adjustments). Further, prospective studies are required to evaluate the possible benefit of interventions aiming at reducing urinary osmolarity as a potential treatment for slowing chronic kidney disease progression.

Developing hypothetical inhibition mechanism of novel urea transporter B inhibitor

Urea transporter B (UT-B) is a membrane channel protein that specifically transports urea. UT-B null mouse exhibited urea selective urine concentrating ability deficiency, which suggests the potential clinical applications of the UT-B inhibitors as novel diuretics. Primary high-throughput virtual screening (HTVS) of 50000 small-molecular drug-like compounds identified 2319 hit compounds. These 2319 compounds were screened by high-throughput screening using an erythrocyte osmotic lysis assay. Based on the pharmacological data, putative UT-B binding sites were identified by structure-based drug design and validated by ligand-based and QSAR model. Additionally, UT-B structural and functional characteristics under inhibitors treated and untreated conditions were simulated by molecular dynamics (MD). As the result, we identified four classes of compounds with UT-B inhibitory activity and predicted a human UT-B model, based on which computative binding sites were identified and validated. A novel potential mechanism of UT-B inhibitory activity was discovered by comparing UT-B from different species. Results suggest residue PHE198 in rat and mouse UT-B might block the inhibitor migration pathway. Inhibitory mechanisms of UT-B inhibitors and the functions of key residues in UT-B were proposed. The binding site analysis provides a structural basis for lead identification and optimization of UT-B inhibitors.

Health effects of protein intake in healthy elderly populations: a systematic literature review

The purpose of this systematic review is to assess the evidence behind the dietary requirement of protein and to assess the health effects of varying protein intake in healthy elderly persons in order to evaluate the evidence for an optimal protein intake. The literature search covered year 2000–2011. Prospective cohort, case–control, and intervention studies of a general healthy population in settings similar to the Nordic countries with protein intake from food-based sources were included. Out of a total of 301 abstracts, 152 full papers were identified as potentially relevant. After careful scrutiny, 23 papers were quality graded as A (highest, n=1), B (n=18), or C (n=4). The grade of evidence was classified as convincing, probable, suggestive, or inconclusive. The evidence is assessed as: probable for an estimated average requirement (EAR) of 0.66 g good-quality protein/kg body weight (BW)/day based on nitrogen balance (N-balance) studies and the subsequent recommended dietary allowance (RDA) of 0.83 g good-quality protein/kg BW/day representing the minimum dietary protein needs of virtually all healthy elderly persons. Regarding the optimal level of protein related to functional outcomes like maintenance of bone mass, muscle mass, and strength, as well as for morbidity and mortality, the evidence is ranging from suggestive to inconclusive. Results from particularly prospective cohort studies suggest a safe intake of up to at least 1.2–1.5 g protein/kg BW/day or approximately 15–20 E%. Overall, many of the included prospective cohort studies were difficult to fully evaluate since results mainly were obtained by food frequency questionnaires that were flawed by underreported intakes, although some studies were ‘calibrated’ to correct for under- or over-reporting. In conclusion, the evidence is assessed as probable regarding the EAR based on N-balance studies and suggestive to inconclusive regarding an optimal protein intake higher than the estimated RDA assessed from N-balance studies, but an exact level cannot be determined. Potentially adverse effects of a protein intake exceeding 20–23 E% remain to be investigated.

Health effects of protein intake in healthy adults: a systematic literature review

The purpose of this systematic review is to assess the evidence behind the dietary requirement of protein and to assess the health effects of varying protein intake in healthy adults. The literature search covered the years 2000-2011. Prospective cohort, case-control, and intervention studies were included. Out of a total of 5,718 abstracts, 412 full papers were identified as potentially relevant, and after careful scrutiny, 64 papers were quality graded as A (highest), B, or C. The grade of evidence was classified as convincing, probable, suggestive or inconclusive. The evidence is assessed as: probable for an estimated average requirement of 0.66 g good-quality protein/kg body weight (BW)/day based on nitrogen balance studies, suggestive for a relationship between increased all-cause mortality risk and long-term low-carbohydrate-high-protein (LCHP) diets; but inconclusive for a relationship between all-cause mortality risk and protein intake per se; suggestive for an inverse relationship between cardiovascular mortality and vegetable protein intake; inconclusive for relationships between cancer mortality and cancer diseases, respectively, and protein intake; inconclusive for a relationship between cardiovascular diseases and total protein intake; suggestive for an inverse relationship between blood pressure (BP) and vegetable protein; probable to convincing for an inverse relationship between soya protein intake and LDL cholesterol; inconclusive for a relationship between protein intake and bone health, energy intake, BW control, body composition, renal function, and risk of kidney stones, respectively; suggestive for a relationship between increased risk of type 2 diabetes (T2D) and long-term LCHP-high-fat diets; inconclusive for impact of physical training on protein requirement; and suggestive for effect of physical training on whole-body protein retention. In conclusion, the evidence is assessed as probable regarding the estimated requirement based on nitrogen balance studies, and suggestive to inconclusive for protein intake and mortality and morbidity. Vegetable protein intake was associated with decreased risk in many studies. Potentially adverse effects of a protein intake exceeding 20-23 E% remain to be investigated.

Vasopressin: a novel target for the prevention and retardation of kidney disease?

After several decades during which little attention was paid to vasopressin and/or urine concentration in clinical practice, interest in vasopressin has renewed with the availability of new, potent, orally active vasopressin-receptor antagonists--the vaptans--and with the results of epidemiological studies evaluating copeptin (a surrogate marker of vasopressin) in large population-based cohorts. Several experimental studies in rats and mice had previously shown that vasopressin, acting via vasopressin V2 antidiuretic receptors, contributes to the progression of chronic kidney disease; in particular, to autosomal dominant polycystic kidney disease. New epidemiological studies now suggest a role for vasopressin in the pathogenesis of diabetes mellitus and metabolic disorders via activation of hepatic V1a and/or pancreatic islet V1b receptors. The first part of this Review describes the adverse effects of vasopressin, as revealed by clinical and experimental studies in kidney diseases, hypertension, diabetes and the metabolic syndrome. The second part provides insights into vasopressin physiology and pathophysiology that may be relevant to the understanding of these adverse effects and that are linked to the excretion of concentrated nitrogen wastes and associated hyperfiltration. Collectively, the studies reviewed here suggest that more attention should be given to the vasopressin-thirst-urine concentration axis in clinical investigations and in patient care. Whether selective blockade of the different vasopressin receptors may provide therapeutic benefits beyond their present indication in hyponatraemia requires new clinical trials.

Structure and permeation mechanism of a mammalian urea transporter

As an adaptation to infrequent access to water, terrestrial mammals produce urine that is hyperosmotic to plasma. To prevent osmotic diuresis by the large quantity of urea generated by protein catabolism, the kidney epithelia contain facilitative urea transporters (UTs) that allow rapid equilibration between the urinary space and the hyperosmotic interstitium. Here we report the first X-ray crystal structure of a mammalian UT, UT-B, at a resolution of 2.36 Å. UT-B is a homotrimer and each protomer contains a urea conduction pore with a narrow selectivity filter. Structural analyses and molecular dynamics simulations showed that the selectivity filter has two urea binding sites separated by an approximately 5.0 kcal/mol energy barrier. Functional studies showed that the rate of urea conduction in UT-B is increased by hypoosmotic stress, and that the site of osmoregulation coincides with the location of the energy barrier.

New insights into urea and glucose handling by the kidney, and the urine concentrating mechanism

The mechanism by which urine is concentrated in the mammalian kidney remains incompletely understood. Urea is the dominant urinary osmole in most mammals and may be concentrated a 100-fold above its plasma level in humans and even more in rodents. Several facilitated urea transporters have been cloned. The phenotypes of mice with deletion of the transporters expressed in the kidney have challenged two previously well-accepted paradigms regarding urea and sodium handling in the renal medulla but have provided no alternative explanation for the accumulation of solutes that occurs in the inner medulla. In this review, we present evidence supporting the existence of an active urea secretion in the pars recta of the proximal tubule and explain how it changes our views regarding intrarenal urea handling and UT-A2 function. The transporter responsible for this secretion could be SGLT1, a sodium-glucose cotransporter that also transports urea. Glucagon may have a role in the regulation of this secretion. Further, we describe a possible transfer of osmotic energy from the outer to the inner medulla via an intrarenal Cori cycle converting glucose to lactate and back. Finally, we propose that an active urea transporter, expressed in the urothelium, may continuously reclaim urea that diffuses out of the ureter and bladder. These hypotheses are all based on published findings. They may not all be confirmed later on, but we hope they will stimulate further research in new directions.

UT-B-deficient mice develop renal dysfunction and structural damage

BACKGROUND

Urea transporter UT-B is the major urea transporter in erythrocytes and the descending vasa recta in the kidney. In this study, we investigated the effects of long-term UT-B deficiency on functional and structural defect in the kidney of 16-and 52-week-old UT-B-null mice.

METHODS

UT-B-knockout mice were generated by targeted gene disruption and lacked UT-B protein expression in all organs. The urinary concentrating ability of mice was studied in terms of daily urine output, urine osmolality, and urine and plasma chemistries. Changes in renal morphology were evaluated by hematoxylin and eosin staining.

RESULTS

The UT-B-null mice showed defective urine concentrating ability. The daily urine output in UT-B-null mice (2.5 ± 0.1 ml) was 60% higher and urine osmolality (985 ± 151 mosm) was significantly lower than that in wild-type mice (1463 ± 227 mosm). The 52-week-old UT-B-null mice exhibited polyuria after water deprivation, although urine osmolality was increased. At 52 weeks of age, over 31% of UT-B-null mice exhibited renal medullary atrophy because of severe polyuria and hydronephrosis.

CONCLUSIONS

Long-term UT-B deficiency causes severe renal dysfunction and structural damage. These results demonstrate the important role of UT-B in countercurrent exchange and urine concentration.

Treatment of the syndrome of inappropriate secretion of antidiuretic hormone with urea in critically ill patients

BACKGROUND

Hyponatremia occurring as a result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a common and potentially lethal complication in critically ill patients. Urea, by inducing renal water excretion and promoting sodium (Na) retention, has been well described as a treatment for chronic SIADH. However, there are limited data on its use for the treatment of SIADH as encountered in patients admitted to the intensive care unit (ICU). We assessed the effects of urea administration for treatment of SIADH in ICU patients.

METHODS

Data from ICU patients treated with urea for SIADH between January 2000 and August 2010 were reviewed. The time courses of Na and urea concentrations were analyzed by variance analysis (ANOVA).

RESULTS

Records from 24 patients were analyzed. The most common etiology of SIADH was neurological (18 patients). Before urea administration, the mean serum Na concentration was 124.8 ± 5.9 mEq/l. There was a significant increase in serum Na from the second day of treatment (131.4 ± 3.5 mEq/l, p < 0.001) and a normalization of mean serum Na by the fourth day (136.2 ± 4.1 mEq/l, p < 0.001). The mean serum urea concentration also increased (from 29.8 ± 11.1 mg/dl before urea to 57.6 ± 24.0 mg/dl on the first day of treatment, p < 0.001).

CONCLUSIONS

Urea administration appears useful for the treatment of SIADH-associated hyponatremia in critically ill patients. Prospective randomized controlled studies are needed to confirm these results.

Volume depletion versus dehydration: how understanding the difference can guide therapy

Although often used interchangeably, dehydration and volume depletion are not synonyms. Dehydration refers to loss of total-body water, producing hypertonicity, which now is the preferred term in lieu of dehydration, whereas volume depletion refers to a deficit in extracellular fluid volume. In particular, hypertonicity implies intracellular volume contraction, whereas volume depletion implies blood volume contraction. Using a case of hyperglycemic hypertonic nonketosis as an example, we examine the changing composition of body fluid spaces to explore the distinction between dehydration and hypertonicity from volume depletion.

Effects of high-whey-protein intake and resistance training on renal, bone and metabolic parameters in rats

Consumption of high-protein (HP) diets is postulated to exert a negative influence on bone and renal health. However, no conclusive evidence has been presented related to this issue or to the potential protective action of resistance training on HP-induced systemic effects. We examined the effects of HP diet consumption on food intake, body-weight gain, body composition, and renal, bone and metabolic parameters of rats performing resistance training. A total of ninety-six adult male Wistar rats were randomly distributed in twelve experimental groups (n 8): normal-protein (10 %) or HP (45 %) diets, with or without resistance training, killed for experimental periods of 1, 2 or 3 months. Diets were based on a commercial whey protein hydrolysate. Consumption of HP diets and resistance training significantly affected food intake, body weight and body composition, as well as the plasma levels of total cholesterol, HDL-cholesterol and TAG. The buffering action of resistance training on such diet-induced alterations was especially evident in the levels of plasma TAG. Consumption of HP diets led to a considerable increase in kidney weight, urinary volume and acidity, as well as in the urinary excretion of Ca, with a parallel reduction in the urinary excretion of citrate (P < 0·05). No apparent deleterious effect on bone mineral content was found. In conclusion, consumption of HP diets caused alterations in renal health status and some metabolic parameters, but did not seem to affect bone status. Resistance training had a protective action against alterations of renal health status and some metabolic parameters such as plasma TAG.

Vasopressin V2 receptors, ENaC, and sodium reabsorption: a risk factor for hypertension?

Excessive sodium reabsorption by the kidney has long been known to participate in the pathogenesis of some forms of hypertension. In the kidney, the final control of NaCl reabsorption takes place in the distal nephron through the amiloride-sensitive epithelial sodium channel (ENaC). Liddle's syndrome, an inherited form of hypertension due to gain-of-function mutations in the genes coding for ENaC subunits, has demonstrated the key role of this channel in the sodium balance. Although aldosterone is classically thought to be the main hormone regulating ENaC activity, several studies in animal models and in humans highlight the important effect of vasopressin on ENaC regulation and sodium transport. This review summarizes the effect of vasopressin V2 receptor stimulation on ENaC activity and sodium excretion in vivo. Moreover, we report the experimental and clinical data demonstrating the role of renal ENaC in water conservation at the expense of a reduced ability to excrete sodium. Acute administration of the selective V2 receptor agonist dDAVP not only increases urine osmolality and reduces urine flow rate but also reduces sodium excretion in rats and humans. Chronic V2 receptor stimulation increases blood pressure in rats, and a significant correlation was found between blood pressure and urine concentration in healthy humans. This led us to discuss how excessive vasopressin-dependent ENaC stimulation could be a risk factor for sodium retention and resulting increase in blood pressure.

Vasopressin in chronic kidney disease: an elephant in the room?

Perico et al. report that a dual arginine vasopressin (AVP) V(2) and V(1a) receptor antagonist lowers blood pressure, proteinuria, and glomerulosclerosis in 5/6 nephrectomized rats, pointing to its potential value in the treatment of chronic kidney disease (CKD). AVP likely contributes to CKD progression by its effects on renal hemodynamics, blood pressure, and mesangial and/or epithelial cells, but the relative contributions of V(2) and V(1a) receptors and potential usefulness of V(2) and V(1a) receptor antagonists remain ill defined.

Kidney function in the Spinifex hopping mouse, Notomys alexis

Notomys alexis (Spinifex hopping mouse) is found in the arid zone of Australia. The structure and function of the kidneys allow this species to conserve water. This study investigated the rate at which N. alexis can reduce urine volume and increase the concentration of electrolytes and solutes when water deprived. It also looked at the response to rehydration, following a period of water deprivation. The laboratory mouse, Mus musculus domesticus, was used for comparison. N. alexis is able to reduce urine volume and increase urine concentration more rapidly than M. m. domesticus when water deprived. This appears to occur prior to any measurable changes in plasma electrolyte concentrations and is not due to reductions in glomerular filtration rate. Gradual water deprivation over a period of 10 days allowed N. alexis to adjust so that urine composition was similar in many ways to animals that had ad libitum access to water, whereas M. m. domesticus required significant water supplementation to maintain body weight at 85% of initial body weight. Ability to concentrate urine rapidly is characteristic of a well-insulated renal medulla [Bankir, L., DeRouffignac, C., 1985. Urinary concentrating ability: insights from comparative anatomy. Am. J. Physiol. 249, R643-666]. However, a well-insulated medulla is normally associated with slow dilution of urine when animals are rehydrated. N. alexis was able to produce dilute urine very rapidly following rehydration of water deprived animals. Physiological control of renal function appears to be complex. Although M. m. domesticus is able to produce concentrated urine, it is unable to survive without free water and responds more slowly to water deprivation.

[Difference in urine concentration according to gender and ethnicity: possible involvement in the different susceptibility to various renal and cardiovascular diseases]

Men and African-Americans are known to be at greater risk of urolithiasis and cardiovascular and renal diseases than women and Caucasians. Previous studies suggest that the antidiuretic effects of vasopressin and/or a greater urine concentration are associated with the rate of progression of these diseases. The present review addresses possible sex and ethnic-related differences in urine volume and osmolality which could participate in this male and black higher predominance. We reanalyzed 24h-urine data collected previously by different investigators for other purposes. In studies concerning healthy subjects (six studies) or patients with chronic kidney disease or Diabetes mellitus (three studies), men excreted a larger osmolar load than women, with a 15 to 30% higher urinary osmolality (or another index of urine concentration based on the urine/plasma creatinine concentration ratio) and a similar 24h urine volume than in women. In two American studies, African-Americans showed a significantly higher urinary concentration than Caucasians and a lower 24h-urine volume. Sex and ethnic differences in thirst threshold, vasopressin level, or other regulatory mediators may contribute to the higher urinary concentration of men and of African Americans. These differences could play a role in the greater susceptibility of these subjects to these pathologies. New prospective studies should take into account the antidiuretic effects of vasopressin as a potential risk factor in the initiation and progression of cardiovascular and renal diseases.

Sex difference in urine concentration across differing ages, sodium intake, and level of kidney disease

Men are known to be at greater risk of urolithiasis and cardiovascular and renal diseases than women. Previous studies suggest that greater urine concentration is associated with acceleration of progression of chronic kidney disease (CKD), increased urinary albumin excretion, and delayed renal sodium excretion. The present review addresses possible sex-related differences in urine volume and osmolality (U(osm)) that could participate in this male risk predominance. Because of the scarcity of information, we reanalyzed 24-h urine data collected previously by different investigators for other purposes. In nine studies concerning healthy subjects (6 studies) or patients with CKD or diabetes mellitus, U(osm) (or another index of urine concentration based on the urine/plasma creatinine concentration ratio) was 21-39% higher (i.e., about a 150 mosm/kgH2O difference) in men than in women. Urine volume was not statistically different. Thus, the larger osmolar load of men (related to their higher food intake) is excreted in a more concentrated urine with no difference in urine volume. This sex difference was not influenced by the level of sodium excretion and was still present in CKD patients. Sex differences in thirst threshold, AVP level, and other regulatory mediators may all contribute to the higher male U(osm). Because of the previously demonstrated adverse effects of vasopressin and/or high urine concentrating activity, the greater tendency of men to concentrate urine could participate in their greater susceptibility to urolithiasis and hypertension and to the faster progression towards end-stage renal failure.

Assessment of renal injury in vivo

The ICH S7A (Safety Pharmacology for Human Pharmaceuticals) guidelines specify that potential adverse pharmacologic effects of a test substance on renal function should be evaluated in supplemental studies when there is a cause for concern (ICH, 2001). For the most part, this can easily be accomplished by examination of the appropriate analytes in urine and blood collected as part of the routine preclinical safety studies. This review will serve as an overview of the selection, interpretation and limitations of standard clinical pathology methods (serum chemistry and urinalysis) for assessment of renal function in such studies, as well as provide some information on emerging biomarkers of renal function.

Dietary protein intake and renal function

Recent trends in weight loss diets have led to a substantial increase in protein intake by individuals. As a result, the safety of habitually consuming dietary protein in excess of recommended intakes has been questioned. In particular, there is concern that high protein intake may promote renal damage by chronically increasing glomerular pressure and hyperfiltration. There is, however, a serious question as to whether there is significant evidence to support this relationship in healthy individuals. In fact, some studies suggest that hyperfiltration, the purported mechanism for renal damage, is a normal adaptative mechanism that occurs in response to several physiological conditions. This paper reviews the available evidence that increased dietary protein intake is a health concern in terms of the potential to initiate or promote renal disease. While protein restriction may be appropriate for treatment of existing kidney disease, we find no significant evidence for a detrimental effect of high protein intakes on kidney function in healthy persons after centuries of a high protein Western diet.