The sympathetic nervous system in hypertension and renal disease

Interactions between microvascular and macrovascular disease in diabetes: pathophysiology and therapeutic implications

Convention partitions the complications of diabetes into two main subtypes. First are the diabetes-specific microvascular complications of retinopathy, nephropathy and neuropathy; second are the atherothrombotic macrovascular complications that account for the majority of premature deaths. Pathological interactions between microvascular and macrovascular complications, for example, nephropathy and macrovascular disease, are common. Similar mechanisms and shared risk factors drive the development and progression of both small and large vessel disease. This concept has therapeutic implications. Mounting evidence points to the need for multifactorial strategies to prevent vascular complications in subjects with diabetes and/or the metabolic syndrome. We advocate a combined therapeutic approach that addresses small and large vessel disease. Preferential use should be made of drug regimens that (i) maximize vascular protection, (ii) reduce the risk of iatrogenic vascular damage and (iii) minimize the increasing problem of polypharmacy.

Suppression of catechol-O-methyltransferase activity through blunting of alpha2-adrenoceptor can explain hypertension in Dahl salt-sensitive rats

Catecholamines have been reported to be involved in the development of salt-sensitive hypertension. We investigated the relation between catechol-O-methyltransferase (COMT) and salt-sensitivity. In the first experiment, Dahl salt-sensitive (DS) rats were given a normal-salt (NS), high-salt (HS), or HS+hydralazine (80 mg/l water) diet for 4 or 13 weeks, and Dahl salt-resistant (DR) rats were given a NS or HS diet. COMT activities in both the kidneys and liver and urinary norepinephrine (NE) and dopamine (DA) excretion were measured. In the second experiment, HepG2 cells were used to investigate the role of NE in regulating COMT activity. In the third experiment, we investigated the reactivity of pre- and postsynaptic alpha(2)-adrenoceptor (AR) in DS rats. HS loading significantly suppressed the activities of membrane-bound COMT (MB-COMT) and, consistent with this finding, increased the urinary NE level in DS rats, but not in DR rats. Hydralazine did not restore the MB-COMT activities, which suggested that HS loading rather than elevated blood pressure suppressed the MB-COMT activities. The in vitro experiment using HepG2 cells revealed that NE increased the MB-COMT activity via the alpha(2)-AR. However, both the pre- and postsynaptic alpha(2)-AR reactivity was decreased by HS loading in DS rats. In conclusion, HS intake suppresses the MB-COMT activities in DS rats, presumably by blunting alpha(2)-AR signaling. The suppression of MB-COMT activities, consequent decrease in degradation of NE, and increase in NE release by blunting of alpha(2)-AR function may be involved in the development of salt-sensitive hypertension in DS rats, in whom DA-dependent natriuresis may be suppressed.

Stenosis-dependent role of nitric oxide and prostaglandins in chronic renal ischemia

The role of nitric oxide (NO) and prostaglandins (PG) in modifying renal hemodynamics was examined in clipped and nonclipped kidneys of unilateral renal artery stenosis. Chronic unilateral renal ischemia was established by 4-wk-clipping the left renal artery of canine kidneys, and renal interstitial nitrate+nitrite and PGE(2) contents were evaluated by the microdialysis technique. Unilateral renal artery stenosis caused 45 +/- 1 and 73 +/- 1% decrements in renal plasma flow (RPF) in moderately and severely clipped kidneys and 21 +/- 3% decrements in nonclipped kidneys with severe stenosis. Renal nitrate+nitrite decreased in moderately (-31 +/- 1%) and severely clipped kidneys (-63 +/- 4%). N(omega)-nitro-L-arginine methyl ester reduced RPF (-56 +/- 3%) and glomerular filtration rate (GFR; -54 +/- 3%) in moderately clipped kidneys, whereas this inhibitory effect was abolished in severely clipped kidneys. In contrast, renal PGE(2) contents increased modestly in moderate clipping and were markedly elevated in severely clipped kidneys (from 111 +/- 7 to 377 +/- 22 pg/ml); sulpyrine impaired renal hemodynamics only in severely clipped kidneys. In contralateral nonclipped kidneys, although renal PGE(2) was not increased, sulpyrine reduced RPF (-32 +/- 1%) and GFR (-33 +/- 3%) in severe stenosis. Collectively, NO plays a substantial role in maintaining renal hemodynamics both under basal condition and in moderate renal artery stenosis, whereas the contributory role shifts from NO to PG as renal artery stenosis progresses. Furthermore, because intrarenal angiotensin II is reported to increase in nonclipped kidneys, unilateral severe ischemia may render the nonclipped kidney susceptible to PG inhibition.

Altered baroreflex responses in alpha7 deficient mice

The autonomic nervous system controls and coordinates several cardiovascular functions, including heart rate, arterial pressure, blood flow and vasomotor tone. Neuronal nicotinic acetylcholine receptors (nAChRs) are the interface between the nervous system and the cardiovascular system, but it is not known which nAChR subtypes regulate autonomic function in vivo. Nicotinic AChRs containing the alpha7 subunit are a candidate subtype in autonomic ganglia. Stimulation of these nAChRs can increase neurotransmitter release via presynaptic mechanisms, as well as mediate fast synaptic transmission via postsynaptic mechanisms. To investigate the role of the alpha7 nAChR subunit in cardiac autonomic function, we measured baroreflex-mediated responses in alpha7 null mice. Here we show that the alpha7 null mice have impaired sympathetic responses to vasodilatation, as sodium nitroprusside infusion triggered a 48% heart rate increase in wild type mice but only a 21% increase in the alpha7 nulls (P < 0.001). The mutant mice developed supersensitivity to adrenergic agonists, although norepinephrine release from sympathetic nerve terminals could be elicited through mechanisms alternative to nAChR stimulation. Baroreflex-mediated parasympathetic responses were normal in alpha7 null mice. The decreased baroreflex-mediated tachycardia in alpha7 mutant mice indicates that alpha7-containing nAChRs participate in the autonomic reflex that maintains blood pressure homeostasis. The alpha7 mutant mice may serve as a model of baroreflex impairment arising from autonomic dysfunction.

Hypertension in end-stage renal disease

Patients with moderate to severe renal disease have a very high incidence of hypertension. In end-stage renal disease (ESRD) this is true regardless of the nature of the underlying renal disease. Nevertheless, patients with glomerular diseases and autosomal dominant polycystic kidney disease are particularly vulnerable. Evidence is presented that ESRD hypertension is the result of extracellular volume expansion, increased or inappropriate response of the renin-angiotensin system and overactivity of the sympathetic system. In addition, the role of endothelin-1, nitric oxide and other vasodilators, and abnormal ion channels in generating high blood pressure, is considered.

The kidney in blood pressure regulation and development of hypertension

Systemic arterial pressure is a dynamic and responsive physiologic parameter that can be influenced by many different factors. In particular, short-term changes in arterial pressure are caused by a myriad of mechanisms that affect cardiac output, total peripheral resistance, and cardiovascular capacitance. In the long run, however, most of these actions can be buffered or compensated by appropriate renal adjustments of sodium balance, ECFV, and blood volume. As long as the mechanisms regulating sodium excretion can maintain sodium balance by appropriately modulating the sensitivity of the pressure-natriuresis relationship, normal arterial pressure can be sustained. Derangements that compromise the ability of the kidneys to maintain sodium balance, however, can result in the kidney's need for an elevated arterial pressure to reestablish net salt and water balance.