Taurine modulates arginine vasopressin-mediated regulation of renal function

Investigational new drugs for the treatment of chronic renal failure: an overview of the literature

INTRODUCTION

Chronic kidney disease (CKD) is widespread throughout the world, with a high social and health impact. It is considered a 'silent killer' for its sudden onset without symptoms in the early stages of the disease. The main goal of nephrologists is to slow the progression of kidney disease and treat the associated symptoms with a range of new medications.

AREAS COVERED

The aim of this systematic review is to analyze the new investigational drugs for the treatment of chronic renal failure. Data were obtained from the available scientific literature and from the ClinicalTrials.gov website.

EXPERT OPINION

Among the drugs currently being researched, SGLT2 inhibitors appear to be the most promising drugs for the treatment of CKD, has they have slower progression of CKD and protection of cardiorenal function. An important role in the future of CKD treatment is played by autologous cell-therapy, which appears to be a new frontier in the treatment of CKD. Other therapeutic strategies are currently being investigated and have been shown to slow the progression of CKD. However, further studies are needed to determine whether these approaches may offer benefits in slowing the progression of CKD in the near future.

Ameliorative effect of taurine against diabetes and renal-associated disorders (Review)

To develop novel therapeutic methods for both diabetic and renal disorders, scientists had initially focused on elucidating the molecular mechanisms of taurine in established cell lines and mouse models. Although a large amount of data have been revealed, taurine has been confirmed to be the next step of novel promising therapeutic interventions against diabetic disorders. Taurine appears to ameliorate diabetes 1-related complications in various organs through its antioxidant, anti-inflammatory and anti-hormonal actions. In type 2 diabetes, taurine has been positively implicated in glucose homeostasis, exerting potent hypoglycemic, anti-obesity, hypotensive and hypolipidemic effects. Of particular interest is that taurine provides protection against renal dysfunction, including hypertension and proteinuria, specific glomerular and tubular disorders, acute and chronic renal conditions, and diabetic nephropathy. The ameliorative effects of taurine against renal disorders are based on its osmoregulatory properties, its association with signaling pathways and its association with the renin-angiotensin-aldosterone system (RAAS). Further clinical studies are required to ensure the importance of research findings.

Proton Nuclear Magnetic Resonance (¹H-NMR)-Based Metabolomic Evaluation of Human Renal Allografts from Donations After Circulatory Death

BACKGROUND Delayed graft function (DGF) is a common complication that impairs allograft function after kidney transplantation. However, the mechanism of DGF remains unclear. Nuclear magnetic resonance (NMR)-based analysis has been widely used in recent times to assess changes in metabolite levels. MATERIAL AND METHODS Samples of perfusate from allografts donated after circulatory death were collected prior to transplantation, during static cold storage. ¹H-NMR-based metabolomics combined with the statistical methods, orthogonal partial least-squares discriminant analysis (OPLS-DA), and principle-component analysis (PCA), were employed to test different levels of metabolites between the allografts that exhibited DGF and those that exhibited immediate graft function (IGF). RESULTS The study population consisted of 36 subjects, 11 with DGF and 25 with IGF. Of the 37 detected and identified metabolites, a-glucose and citrate were significantly elevated in the perfusate of DGF allografts, and taurine and betaine were significantly decreased. CONCLUSIONS ¹H-NMR analysis of DGF and IGF perfusates revealed some significant differences in their metabolite profiles, which may help explain the mechanisms of kidney ischemia-reperfusion injury and DGF.

Effect of taurine and potential interactions with caffeine on cardiovascular function

The major impetus behind the rise in energy drink popularity among adults is their ability to heighten mental alertness, improve physical performance and supply energy. However, accompanying the exponential growth in energy drink usage have been recent case reports and analyses from the National Poison Data System, raising questions regarding the safety of energy drinks. Most of the safety concerns have centered on the effect of energy drinks on cardiovascular and central nervous system function. Although the effects of caffeine excess have been widely studied, little information is available on potential interactions between the other active ingredients of energy drinks and caffeine. One of the active ingredients often mentioned as a candidate for interactions with caffeine is the beta-amino acid, taurine. Although taurine is considered a conditionally essential nutrient for humans and is thought to play a key role in several human diseases, clinical studies evaluating the effects of taurine are limited. However, based on this review regarding possible interactions between caffeine and taurine, we conclude that taurine should neutralize several untoward effects of caffeine excess. In agreement with this conclusion, the European Union's Scientific Committee on Food published a report in March 2003 summarizing its investigation into potential interactions of the ingredients in energy drinks. At the cardiovascular level, they concluded that "if there are any interactions between caffeine and taurine, taurine might reduce the cardiovascular effects of caffeine." Although these interactions remain to be further examined in humans, the physiological functions of taurine appear to be inconsistent with the adverse cardiovascular symptoms associated with excessive consumption of caffeine-taurine containing beverages.

Differential effects of taurine treatment and taurine deficiency on the outcome of renal ischemia reperfusion injury

Taurine possesses membrane stabilization, osmoregulatory and antioxidant properties, aspects of relevance to ischemic injury. We tested the hypothesis that body taurine status is a determinant of renal ischemic injury. Accordingly, renal function and structure were examined in control (C), taurine-treated (TT) and taurine deficient (TD) rats that were subjected to bilateral renal ischemia (60 min) followed by reperfusion (IR); sham operated rats served as controls. Baseline urine osmolality was greater in the TD group than in the control and the TT groups, an effect associated with increased renal aquaporin 2 level. The IR insult reduced urine osmolality (i.e., day-1 post insult); the TD/IR group displayed a more marked recovery in urine osmolality by day-6 post insult than the other two groups. Fluid and sodium excretions were lower in the TD/IR group, suggesting propensity to retention. Histopathological examination revealed the presence of tubular necrotic foci in the C/IR group than sham controls. While renal architecture of the TD/IR group showed features resembling sham controls, the TT/IR group showed dilated tubules, which lacked immunostaining for aquaporin 2, but not 1, suggestive of proximal tubule origin. Finally, assessment of cell proliferation and apoptosis revealed lower proliferation but higher apoptotic foci in the TT/IR group than other IR groups. Collectively, the results indicate that body taurine status is a major determinant of renal IR injury.

Phenotype of the Taurine Transporter Knockout Mouse

This chapter reports present knowledge on the properties of mice with disrupted gene coding for the taurine transporter (taut-/- mice). Study of those mice unraveled some of the roles of taurine and its membrane transport for the development and maintenance of normal organ functions and morphology. When compared with wild-type controls, taut-/- mice have decreased taurine levels in skeletal and heart muscle by about 98%, in brain, kidney, plasma, and retina by 80 to 90%, and in liver by about 70%. taut-/- mice exhibit a lower body mass as well as a strongly reduced exercise capacity compared with taut+/- and wild-type mice. Furthermore, taut-/- mice show a variety of pathological features, for example, subtle derangement of renal osmoregulation, changes in neuroreceptor expression, and loss of long-term potentiation in the striatum, and they develop clinically relevant age-dependent disorders, for example, visual, auditory, and olfactory dysfunctions, unspecific hepatitis, and liver fibrosis. Taurine-deficient animal models such as acutely dietary-manipulated foxes and cats, pharmacologically induced taurine-deficient rats, and taurine transporter knockout mouse are powerful tools allowing identification of the mechanisms and complexities of diseases mediated by impaired taurine transport and taurine depletion (Chapman et al., 1993; Heller-Stilb et al., 2002; Huxtable, 1992; Lake, 1993; Moise et al., 1991; Novotny et al., 1991; Pion et al., 1987; Timbrell et al., 1995; Warskulat et al., 2004, 2006b). Taurine, which is the most abundant amino acid in many tissues, is normally found in intracellular concentrations of 10 to 70 mmol/kg in mammalian heart, brain, skeletal muscle, liver, and retina (Chapman et al., 1993; Green et al., 1991; Huxable, 1992; Timbrell et al., 1995). These high taurine levels are maintained by an ubiquitous expression of Na(+)-dependent taurine transporter (TAUT) in the plasma membrane (Burg, 1995; Kwon and Handler, 1995; Lang et al., 1998; Liu et al., 1992; Ramamoorthy et al., 1994; Schloss et al., 1994; Smith et al., 1992; Uchida et al., 1992; Vinnakota et al., 1997; Yancey et al., 1975). Taurine is not incorporated into proteins. It is involved in cell volume regulation, neuromodulation, antioxidant defense, protein stabilization, stress responses, and via formation of taurine-chloramine in immunomodulation (Chapman et al., 1993; Green et al., 1991; Huxtable, 1992; Timbrell et al., 1995). On the basis of its functions, taurine may protect cells against various types of injury (Chapman et al., 1993; Green et al., 1991; Huxtable, 1992; Kurz et al., 1998; Park et al., 1995; Stapleton et al., 1998; Timbrell et al., 1995; Welch and Brown, 1996; Wettstein and Häussinger, 1997). In order to examine the multiple taurine functions, murine models have several intrinsic advantages for in vivo research compared to other animal models, including lower cost, maintenance, and rapid reproduction rate. Further, experimental reagents for cellular and molecular studies are widely available for the mouse. In particular, mice can be easily genetically manipulated by making transgene and knockout mice. This chapter focuses on the phenotype of the TAUT-deficient murine model (taut-/-; Heller-Stilb et al., 2002), which may help researchers elucidate the diverse roles of taurine in development and maintenance of normal organ functions and morphology.

Cell cycle checkpoints: the role and evaluation for early diagnosis of senescence, cardiovascular, cancer, and neurodegenerative diseases

Maintenance of genomic integrity is critical for prevention of a wide variety of adverse cellular effects including apoptosis, cellular senescence, and malignant cell transformation. Under stress conditions and even during an unperturbed cell cycle, checkpoint proteins play the key role in genome maintenance by and mediating cellular response to DNA damage, and represent an essential part of the "cellular stress response proteome". Intact checkpoint signal transduction cascades check the presence of genome damage, trigger cell cycle arrest, and forward the information to the protein core of cell cycle machinery, replication apparatus, repair, and/or apoptotic protein cores. Genetic checkpoint defects lead to syndromes that demonstrate chromosomal instability, increased sensitivity to genotoxic stress, tissue degeneration, developmental retardation, premature aging, and cancer predisposition that is most extensively studied for the ATM-checkpoint mutated in Ataxia telangiectasia. Tissue specific epigenetic control over the function of cell cycle checkpoints can be, further, misregulated by aberrant DNA methylation status. The consequent checkpoint dysregulation may result in tissue specific degenerative processes such as degeneration and calcification of heart aortic valves, diabetic cardiomyopathy, hyperhomocysteinemic cerebrovascular, peripheral vascular and coronary heart diseases, neurodegenerative disorders (Alzheimer and Parkinson diseases, amyotrophic lateral sclerosis, glaucoma), and accelerated aging frequently accompanied with cancer. This review focuses on the checkpoints shown to be crucial for unperturbed cell cycle regulation, dysregulation of which might be considered as a potential molecular marker for early diagnosis of and therapy efficiency in neurodegenerative, cardiovascular and cancer diseases. An application of the most potent detection technologies such as "Disease Proteomics and Transcriptomics" also considered here, allows a most specific selection of diagnostic markers.

Accelerated NaCl-induced hypertension in taurine-deficient rat: Role of renal function

Taurine modulates blood pressure and renal function. As the kidney plays a pivotal role in long-term control of arterial pressure, we tested the hypothesis that taurine-deficient rats display maladaptive renal and blood pressure responses to uninephrectomy. Control and taurine-deficient (i.e., beta-alanine-treated) rats with either one or two remaining kidneys were fed diets containing basal or high (8%) NaCl diet. Urine osmolality was greater in the taurine-deficient than controls fed a normal NaCl diet; proteinuria and blood pressure were unaffected by uninephrectomy. Following 6 weeks on an 8% NaCl diet, the uninephrectomized (UNX) animals developed significant hypertension, which was more severe in the taurine-deficient group; baroreflex function was unaffected. However, the UNX taurine-deficient rats displayed impaired ability to dispose of an acute isotonic saline volume load before a switchover to a high NaCl diet. Nonetheless, a more protracted exposure (i.e., 14 weeks) to dietary NaCl excess eliminated the blood pressure differential between the two groups; at this stage, renal excretory responses to an acute saline volume load or to atrial natriuretic peptide were similar in the two groups. Nonetheless, hypertensive taurine-deficient rats displayed greater proteinuria, although both groups excreted proteins of similar molecular weights ( approximately 15-66 kDa). Further, taurine-deficient kidney specimens displayed periarterial mononuclear cell infiltrates with strong immunoreactivity to the histiocyte marker CD68, suggestive of increased phagocytic activity. In conclusion, taurine deficiency modulates renal adaptation to combined uninephrectomy and dietary NaCl excess, resulting in an accelerated development of hypertension.

Diuretic potential of energy drinks

Recent literature suggests that both caffeine and taurine can induce diuresis and natriuresis in rat and man. Although they act via different cellular mechanisms, their diuretic actions might be additive. This is of considerable interest, as several commercially available energy drinks contain both substances. In this study we examined the possible diuretic effects of caffeine and taurine in a cross-over-design in which 12 healthy male volunteers received each of 4 different test drinks (750 ml of energy drink containing 240 mg caffeine and 3 g taurine, the three other test drinks either lacked caffeine, taurine or both) after restraining from fluids for 12 h. Mixed model analyses demonstrated that urinary output and natriuresis were significantly increased by caffeine (mean differences 243 ml and 27 mmol; both p < 0.001) and that there were no such effects of taurine (mean differences 59 ml and -4 mmol). Additionally, urinary osmolarity at baseline was significantly related to the urinary output (p < 0.001). Urine osmolarity values at baseline and in the 6 h urine collection did not differ significantly between treatments. Taken together, our study demonstrates that diuretic and natriuretic effects of the tested energy drink were largely mediated by caffeine. Taurine played no significant role in the fluid balance in moderately dehydrated healthy young consumers. Consequently, the diuretic potential of energy drinks will not differ significantly from other caffeine containing beverages.

Effects of dietary salt and fat on taurine excretion in healthy and diseased rats

Taurine modulates renal and cardiovascular function. Although the kidney regulates body taurine status, the impact of renal and cardiovascular risk factors, such as dietary intake of excess NaCl and saturated fat, on renal handling of taurine is less clear. One would predict that the kidney would modulate taurine excretion during dietary NaCl excess to insure adequate osmotic homeostasis. Similarly, fat feeding would be expected to affect taurine homeostasis, as taurine is involved in bile acid conjugation and therefore fat emulsification. To examine these aspects, male rats were divided into four groups: basal fat diet (control), high fat diet (FAT), basal fat and high salt diet (SALT) and a combination of a high fat and salt diet (FATSALT). While the control, FAT and SALT groups excreted similar amounts of taurine; the SALTFAT group excreted significantly more taurine than the other 3 groups. Although all of the dietary regimens increased renal tissue content of taurine, the increases were greatest in the two SALT groups. In a subsequent study, we examined the effect of excess dietary fat on taurine handling by the hypertensive (H) and hypertensive-glucose intolerant (HGI) rat. When fed a basal fat diet, the HGI group excreted more taurine than the H group, an effect likely related to increased endogenous taurine biosynthesis, alterations in renal function or a combination of the two effects. While excess fat intake increased urinary taurine excretion in the H group, it reduced taurine excretion in the HGI group. Nonetheless, kidney taurine content was similar in the 4 groups. Taken together, the data suggest that dietary constituents and preexisting systemic disorders are important modulators of renal handling of taurine.

Impaired ability to increase water excretion in mice lacking the taurine transporter gene TAUT

Cellular taurine uptake or release counteracts alterations of cell volume. Na+-coupled taurine transporter TAUT mediates concentrative cellular uptake of taurine. Inhibition of vasopressin secretion by hypotonicity may involve taurine release from glial cells of supraoptic nucleus. We compared renal function of mice lacking TAUT (taut-/-) and wild-type littermates (taut+/+). We observed renal taurine loss and subsequent hypotaurinemia in taut-/- mice. With free access to water, plasma and urine osmolality, urinary flow rate as well as urinary excretion and plasma concentrations of Na+ and K+ were similar in taut-/- and taut+/+ mice, whereas plasma concentrations of urea were enhanced in taut-/- mice. An oral water load (1 ml/16 g body weight) induced a similar diuresis in both genotypes. Repeating the oral water load immediately after normalization of urine flow rate, however, resulted in delayed diuresis and higher urinary vasopressin/creatinine ratios in taut-/- mice. In comparison, the repeated diuretic response to vasopressin V2 receptor blockade was not different between genotypes. Water deprivation for 36 h led to similar antidiuresis and increases of urinary osmolality in both genotypes. Upon free access to water after deprivation, taut-/- mice continued to concentrate urine up to 6 days, while taut+/+ mice rapidly returned to normal urinary osmolality. Urinary vasopressin/creatinine ratios and plasma aldosterone concentrations were not different under basal conditions but were significantly higher in taut-/- mice than in taut+/+ mice at 6 days after water deprivation. In conclusion, taut-/- mice suffer from renal taurine loss and impaired ability to lower urine osmolality and to increase urinary water excretion. The latter defect could reside extrarenally and result from a role of taurine in the suppression of vasopressin release which may be attenuated in taut-/- mice.

Effect of taurine deficiency on adenosine receptor-mediated relaxation of the rat aorta

We recently demonstrated that chronic taurine supplementation or deficiency causes alterations in reactivity of the rat aorta to several vasoactive agents. In the present investigation, we examined the effects beta-alanine-induced endogenous taurine deficiency on the mechanical responsiveness of the isolated rat aorta to adenosine receptor stimulation with 2-chloroadenosine (CAD), 5'-N-ethylcarboxyamidoadenosine (NECA), and N(6)-cyclopentyladenosine (CPA). The adenosine analogs produced concentration-dependent (1 x 10(-9)-3 x 10(-3) M) relaxations of aortas from both control and beta-alanine-treated rats with the rank order of potencies NECA>CAD>CPA, which was consistent with A(2) receptor identification. CAD and NECA induced both endothelium-dependent and -independent relaxations of the aortas. The endothelium-dependent responses to both agents and the independent responses to CAD were significantly attenuated by beta-alanine treatment. The relaxation responses of the aortas from control and taurine-deficient rats to CAD and NECA were markedly antagonized by ZM241385 (10(-5) M), suggesting the involvement of A(2A) adenosine receptors. Further, N-nitro-L-arginine methyl ester (L-NAME; 10(-5) M) significantly attenuated the endothelium-mediated relaxation produced by CAD and NECA in both groups. However, the inhibitory effect of L-NAME was less on the beta-alanine-treated tissues, providing evidence that the effect of taurine deficiency was linked to a reduction in nitric oxide generation. As in the aorta, CAD produced both endothelium-dependent and -independent relaxation responses in the rat superior mesenteric artery, and both responses were inhibited by chronic beta-alanine treatment, suggesting that not only similar responses can be generated by a given adenosine agonist in different vascular beds, but also beta-alanine treatment modulates these responses. On the other hand, while CPA elicited only endothelium-independent aortic relaxation, this response was not altered by taurine deficiency. The results indicate that endogenous taurine deficiency causes differential inhibitory effects on adenosine receptor-mediated vasorelaxation, depending upon the agonists used. Given the recognized role of adenosine in the vasculature, these alterations suggest taurine-mediated modulation of blood flow regulation.

Taurine depletion alters vascular reactivity in rats

We recently showed that chronic taurine supplementation is associated with attenuation of contractile responses of rat aorta to norepinephrine and potassium chloride. However, the potential involvement of endogenous taurine in modulation of vascular reactivity is not known. Therefore, we examined the effect of β-alanine-induced taurine depletion on the in vitro reactivity of rat aorta to selected vasoactive agents. The data indicate that both norepinephrine- and potassium-chloride-induced maximum contractile responses of endothelium-denuded aortae were enhanced in taurine-depleted rats compared with control animals. However, taurine depletion did not affect tissue sensitivity to either norepinephrine or potassium chloride. By contrast, sensitivity of the endothelium-denuded aortae to sodium nitroprusside was attenuated by taurine depletion. Similarly, taurine deficiency reduced the relaxant responses of endothelium-intact aortic rings elicited by submaximal concentrations of acetylcholine, and this effect was associated with decreased nitric oxide production. Taken together, the data suggest that taurine depletion augments contractility but attenuates relaxation of vascular smooth muscle in a nonspecific manner. Impairment of endothelium-dependent responses, which is at least in part associated with reduced nitric oxide generation, may contribute to the attenuation of the vasorelaxant responses. These vascular alterations could be of potential consequence in pathological conditions associated with taurine deficiency.Key words: rat aorta, β-alanine, taurine depletion, vascular reactivity.

DNA damage and expression of checkpoint genes p21(WAF1/CIP1) and 14-3-3 sigma in taurine-deficient cardiomyocytes

OBJECTIVE

Taurine depletion is associated with development of cardiomyopathy. Further, oxidative stress is advanced as a critical factor mediating the effect of taurine deficiency on target organs. However, the molecular mechanism(s) linking taurine deficiency with the development of cardiomyopathy remains elusive. Since transition between apoptotic degeneration and cell proliferation in stress conditions is regulated at cell cycle checkpoints, we determined the expression of two such genes, namely p21(WAF1/CIP1) and 14-3-3 sigma as well as p53 that are responsible for oxidative stress and DNA damage. We also carried out quantitative determination of DNA damage.

METHODS

Cardiomyocytes from beta-alanine-induced taurine-depleted (TD) rats were used for this investigation. Single- and double-stranded DNA damage was quantified using comet assay analysis. Western blot and two-dimensional polyacrylamide gel electrophoresis with immunoblotting analysis were applied for protein analysis.

RESULTS

Comet assay analysis indicated that the extent of double-stranded DNA damage was greater in TD than in control cardiomyocytes. Whereas only traces of both p53 and p21(WAF1/CIP1) and no detectable expression of 14-3-3 sigma were found in cardiomyocytes of control animals, the TD cardiomyocytes expressed all three genes.

CONCLUSIONS

DNA damage and the consequent up-regulation of checkpoint proteins observed in TD cardiomyocytes indicate the involvement of cell cycle control mechanisms in the effect of taurine deficiency on cardiomyocytes. Single- and double-stranded DNA damage and the consequent arrest of cell proliferation in both G(1) and G(2) phases of the cell cycle induced by checkpoint proteins may trigger the cardiomyopathy that is associated with taurine deficiency.

Chronic taurine treatment ameliorates reduction in saline-induced diuresis and natriuresis

BACKGROUND

Taurine is an osmolyte found in high concentration in the kidney. Both the modulation of tissue taurine stores and the exogenous administration of taurine are known to affect renal function. Therefore, it is likely that taurine therapy could benefit the dysfunctional kidney.

METHODS

To test this idea, the present study examined the effect of chronic taurine administration on the excretory responses to acute saline volume loading by the unilaterally nephrectomized (UNX) control and the UNX glucose-intolerant rat (ages 3 to 9 months).

RESULTS

Sham-operated animals excreted similar amounts of the administered fluid and sodium loads with age. However, unilateral nephrectomy was associated with a significant reduction in the response to saline volume loading. This defect was prominent at a younger age (that is, 3 months) in the UNX glucose intolerant than the UNX control (6 months old) rat. Chronic taurine treatment ameliorated the reduction in saline-induced diuresis and natriuresis by both the UNX control and the UNX glucose intolerant rat. Both an increase in glomerular filtration and a reduction in tubular reabsorption of fluid and sodium caused this taurine-mediated improvement in renal excretory function.

CONCLUSION

Taurine treatment protects the kidney of the UNX rat against an age-dependent decline in excretory efficiency.

Taurine in submandibular gland of the rat: effect of muscarinic drugs

Taurine exerts a number of actions in mammalian cells, including regulation of ion transport and osmoregulation. The production and secretion of saliva involve transepithelial ion transport, thereby making the plasma-like primary saliva hypotonic before secretion. Therefore, it is plausible to suggest modulation of salivary taurine by muscarinic agents that affect salivary gland function. One of the objectives of this study was to determine tissue content and localization of taurine in the submandibular gland of the rat. Further, we determined whether treatment with muscarinic drugs that either increase (e.g., pilocarpine) or decrease (e.g., propantheline) saliva secretion affects the submandibular gland taurine content. The results indicate that the submandibular gland contains an appreciable amount of taurine (8.9 +/- 0.3 micromoles/g wet wt). Further, acute treatment of the rats with either of the muscarinic drugs did not significantly affect tissue taurine content compared to the control group. By contrast, chronic treatment with propantheline, but not pilocarpine, reduced the tissue content of taurine compared to the control rats (p<0.05). Utilizing light microscopic immunohistochemical techniques, intense immunoreactivity was found primarily in the striated ducts of the submandibular gland. Neither pilocarpine nor propantheline treatment led to differential distribution of immunoreactivity in this tissue. In conclusion, the submandibular gland contains an appreciable amount of taurine, primarily in the striated ducts, that can be decreased by chronic muscarinic receptor blockade.