Effects of acetazolamide and acid-base changes on biliary and pancreatic secretion

Hepatobiliary acid-base homeostasis: Insights from analogous secretory epithelia

Many epithelia secrete bicarbonate-rich fluid to generate flow, alter viscosity, control pH and potentially protect luminal and intracellular structures from chemical stress. Bicarbonate is a key component of human bile and impaired biliary bicarbonate secretion is associated with liver damage. Major efforts have been undertaken to gain insight into acid-base homeostasis in cholangiocytes and more can be learned from analogous secretory epithelia. Extrahepatic examples include salivary and pancreatic duct cells, duodenocytes, airway and renal epithelial cells. The cellular machinery involved in acid-base homeostasis includes carbonic anhydrase enzymes, transporters of the solute carrier family, and intra- and extracellular pH sensors. This pH-regulatory system is orchestrated by protein-protein interactions, the establishment of an electrochemical gradient across the plasma membrane and bicarbonate sensing of the intra- and extracellular compartment. In this review, we discuss conserved principles identified in analogous secretory epithelia in the light of current knowledge on cholangiocyte physiology. We present a framework for cholangiocellular acid-base homeostasis supported by expression analysis of publicly available single-cell RNA sequencing datasets from human cholangiocytes, which provide insights into the molecular basis of pH homeostasis and dysregulation in the biliary system.

Transepithelial bicarbonate secretion: lessons from the pancreas

Many cystic fibrosis transmembrane conductance regulator (CFTR)-expressing epithelia secrete bicarbonate (HCO(3)(-))-containing fluids. Recent evidence suggests that defects in epithelial bicarbonate secretion are directly involved in the pathogenesis of cystic fibrosis, in particular by building up hyperviscous mucus in the ductal structures of the lung and pancreas. Pancreatic juice is one of the representative fluids that contain a very high concentration of bicarbonate among bodily fluids that are secreted from CFTR-expressing epithelia. We introduce up-to-date knowledge on the basic principles of transepithelial bicarbonate transport by showing the mechanisms involved in pancreatic bicarbonate secretion. The model of pancreatic bicarbonate secretion described herein may also apply to other exocrine epithelia. As a central regulator of bicarbonate transport at the apical membrane, CFTR plays an essential role in both direct and indirect bicarbonate secretion. The major role of CFTR in bicarbonate secretion would be variable depending on the tissue and cell type. For example, in epithelial cells that produce a low concentration of bicarbonate-containing fluid (up to 80 mm), either CFTR-dependent Cl(-)/HCO(3)(-) exchange or CFTR anion channel with low bicarbonate permeability would be sufficient to generate such fluid. However, in cells that secrete high-bicarbonate-containing fluids, a highly selective CFTR bicarbonate channel activity is required. Therefore, understanding the molecular mechanism of transepithelial bicarbonate transport and the role of CFTR in each specific epithelium will provide therapeutic strategies to recover from epithelial defects induced by hyposecretion of bicarbonate in cystic fibrosis.

Molecular mechanism of pancreatic and salivary gland fluid and HCO3 secretion

Fluid and HCO(3)(-) secretion is a vital function of all epithelia and is required for the survival of the tissue. Aberrant fluid and HCO(3)(-) secretion is associated with many epithelial diseases, such as cystic fibrosis, pancreatitis, Sjögren's syndrome, and other epithelial inflammatory and autoimmune diseases. Significant progress has been made over the last 20 years in our understanding of epithelial fluid and HCO(3)(-) secretion, in particular by secretory glands. Fluid and HCO(3)(-) secretion by secretory glands is a two-step process. Acinar cells secrete isotonic fluid in which the major salt is NaCl. Subsequently, the duct modifies the volume and electrolyte composition of the fluid to absorb the Cl(-) and secrete HCO(3)(-). The relative volume secreted by acinar and duct cells and modification of electrolyte composition of the secreted fluids varies among secretory glands to meet their physiological functions. In the pancreas, acinar cells secrete a small amount of NaCl-rich fluid, while the duct absorbs the Cl(-) and secretes HCO(3)(-) and the bulk of the fluid in the pancreatic juice. Fluid secretion appears to be driven by active HCO(3)(-) secretion. In the salivary glands, acinar cells secrete the bulk of the fluid in the saliva that is driven by active Cl(-) secretion and contains high concentrations of Na(+) and Cl(-). The salivary glands duct absorbs both the Na(+) and Cl(-) and secretes K(+) and HCO(3)(-). In this review, we focus on the molecular mechanism of fluid and HCO(3)(-) secretion by the pancreas and salivary glands, to highlight the similarities of the fundamental mechanisms of acinar and duct cell functions, and to point out the differences to meet gland-specific secretions.

Mechanisms of bicarbonate secretion in the pancreatic duct

In many species the pancreatic duct epithelium secretes HCO3- ions at a concentration of around 140 mM by a mechanism that is only partially understood. We know that HCO3- uptake at the basolateral membrane is achieved by Na+-HCO3- cotransport and also by a H+-ATPase and Na+/H+ exchanger operating together with carbonic anhydrase. At the apical membrane, the secretion of moderate concentrations of HCO3- can be explained by the parallel activity of a Cl-/HCO3- exchanger and a Cl- conductance, either the cystic fibrosis transmembrane conductance regulator (CFTR) or a Ca2+-activated Cl- channel (CaCC). However, the sustained secretion of HCO3- into a HCO- -rich luminal fluid cannot be explained by conventional Cl-/HCO3- exchange. HCO3- efflux across the apical membrane is an electrogenic process that is facilitated by the depletion of intracellular Cl-, but it remains to be seen whether it is mediated predominantly by CFTR or by an electrogenic SLC26 anion exchanger.

Expression and distribution of the Na(+)-HCO(-)(3) cotransporter in human pancreas

The cellular mechanisms of HCO(-)(3) secretion in the human pancreas are unclear. Expression of a Na(+)-HCO(-)(3) cotransporter (NBC) mRNA has been observed recently, but the distribution and physiological role of the NBC protein are not known. Here we examined the expression and localization of NBC in human pancreas by Northern blot, immunoblot, and immunofluorescence microscopy. Rat kidney NBC probes detected a single 9.5-kb band by Northern blot. On immunoblots, two polyclonal antisera directed against different epitopes of rat kidney NBC identified a single approximately 130-kDa protein. In cryosections of normal human pancreas, both antisera labeled basolateral membranes of large, morphologically identifiable ducts and produced a distinct labeling pattern in the remainder of the parenchyma. In double-labeling experiments, NBC immunoreactivity in the parenchyma colocalized with the Na(+)-K(+) pump, a basolateral marker. In contrast, NBC and cystic fibrosis transmembrane conductance regulator, an apical membrane marker, were detected within the same histological structures but at different subcellular localizations. The NBC antisera did not label acinar or islet cells. Our observations suggest that secretion of HCO(-)(3) by human pancreatic duct cells involves the basolateral uptake of Na(+) and HCO(-)(3) via NBC, an electrogenic Na(+)-HCO(-)(3) cotransporter.

Inhibitory effect of ouabain and acetazolamide on secretin-stimulated pancreatic exocrine secretion in anaesthetized dog

1. The effects of ouabain and acetazolamide on the secretion of pancreatic juice stimulated by secretin in anaesthetized dogs were investigated. 2. Intra-arterial injection of ouabain (1-10 micrograms) and acetazolamide (1-10 mg) caused dose-dependent decreases in the volume of pancreatic juice. When both drugs were added together, the inhibitory effects were significantly higher than for each drug alone. 3. The bicarbonate concentration in the pancreatic juice was decreased and the chloride concentration was increased by ouabain and acetazolamide, but sodium and protein concentrations were not modified. 4. The results suggest that the Na+,K+-ATPase and carbonic anhydrase activities play important roles in water and electrolyte secretion, and that ouabain and acetazolamide inhibit secretin-stimulated pancreatic secretion by acting on different systems in the exocrine cells in dogs.

Effects of inhibition of angiotensin converting enzyme and carbonic anhydrase on fluid production by ciliary process, choroid plexus, and pancreas

Inhibitors of angiotensin converting enzyme (ACE) (1) and of carbonic anhydrase (CA) (2,3) decrease intraocular pressure (IOP) in conscious rabbits. We asked whether ACE inhibition decreases IOP through effects on CA-dependent flow of aqueous humor (AH) and whether ACE inhibitors decrease other CA-dependent secretions. We show in anesthetized rabbits (a) that topical inhibitors of ACE decrease both IOP and AH flow as much as systemic inhibitors of CA; (b) that the maximal effects of ACE and CA inhibition are not additive, therefore these treatments may affect one or more components of a single system for fluid production; and that (c) ACE inhibitors do not work through inhibition of CA. Looking at other fluid production systems, we find (d) that cerebrospinal fluid (CSF) production is increased after ventriculocisternal perfusion with a potent ACE inhibitor and (e) that flow of pancreatic juice (PJ) is increased after systemic ACE inhibition.

Importance of carbonic anhydrase for canalicular and ductular choleresis in the pig

To assess the importance of carbonic anhydrase (CA) for canalicular and ductular choleresis, the effect of acetazolamide on bile secretion was measured in three experimental groups of anaesthetized pigs. CA activity in liver homogenate was 46 (43-54) U g-1 wet weight, 150 mg kg-1 b.w. acetazolamide completely abolished the CA activity. Acetazolamide reduced bile HCO3- secretion in six secretin infused, bile-acid depleted pigs by 67 (58-71)% at arterial pH 7.41 (7.38-7.46). By contrast, acetazolamide did not affect HCO3- secretion in six Na-taurocholate (TCA) infused pigs in the absence of secretin stimulation. Acetazolamide reduced ursodeoxycholic-acid- (UDCA) dependent HCO3- secretion by 24 (11-38)% in six other pigs in the absence of secretin stimulation. Histochemical examination using modifications of Hansson's method showed strong reaction in bile ductules and weaker reaction in peripheral zones of liver lobules. Because acetazolamide impairs HCO3- secretion from cells sustaining high rates of H+/HCO3- transport, it is suggested that high rates of H+/HCO3- transport are confined to bile ductules under conditions of secretin- and UDCA-induced choleresis.

Absence of a relationship between arterial pH and pancreatic bicarbonate secretion in the isolated perfused cat pancreas

1. The secretion rate of bicarbonate by the isolated saline-perfused cat pancreas was linearly related to the bicarbonate concentration of the arterial inflow at constant PCO2 and at high volume rates of secretion. 2. Pancreatic bicarbonate secretion was independent of arterial inflow pH at constant bicarbonate concentrations when the pH was manipulated by alterations in the PCO2 at high volume rates of secretion. 3. A small but statistically significant linear relationship existed between the pH of the arterial inflow and bicarbonate secretion at constant PCO2 after inhibition of carbonic anhydrase by acetazolamide. Under the same conditions no relationship was found between bicarbonate secretion and arterial inflow pH when the perfusate bicarbonate concentration was kept constant and the PCO2 varied. 4. When the volume rate of secretion was reduced by about 60-70% of maximum no relationship was found to exist between arterial inflow pH and bicarbonate secretion at constant bicarbonate concentration in the perfusate. There was also no relationship between inflow pH and bicarbonate secretion at constant PCO2 down to a pH of 7.3 until the bicarbonate concentration of the perfusate was reduced below 10 mM, when the secretion rate fell off rapidly. 5. A linear relationship was found to exist between the volume rate of secretion and the PCO2 of the pancreatic juice and the output of lactate both in the isolated saline-perfused gland and the blood-perfused pancreas in situ. 6. At high rates of secretion the PCO2 of the pancreatic juice was always higher than that of either the arterial inflow or the venous outflow. There is therefore no gradient for the passive movement of carbon dioxide between the arterial inflow and the pancreatic juice. 7. Inhibition of secretion with acetazolamide caused a fall in the PCO2 of pancreatic juice and increased the output of lactate. The secretion of lactate was not due to hypoxia as it also occurred in the blood-perfused gland in situ which had normal haemoglobin concentrations and oxygen saturation. 8. It is concluded that the secretion of bicarbonate is independent of arterial pH but critically dependent upon the arterial concentration of the bicarbonate ion. These experiments do not support the concept that the secretion of protons over the basolateral membrane is the major primary event in pancreatic secretion of bicarbonate.

DCCD (N,N'-dicyclohexylcarbodiimide) inhibits biliary secretion of HCO-3

To study whether a proton pump is an integral part of the mechanism responsible for secretin-dependent biliary secretion of HCO-3 ions, the proton pump inhibitor N,N'-dicyclohexylcarbodiimide (DCCD) was systemically administered to six anesthetized, secretin-infused pigs. Because biliary HCO-3 secretion varies with arterial pH, secretion rate was measured at several different arterial pH values, before and after DCCD (25 mumol/kg). At arterial pH 7.45, bile flow was 2.1 (1.6-2.9) ml/min, and HCO-3 secretion was 224 (157-311) mumol/min. DCCD reduced bile flow and HCO-3 secretion by 30% and 40%, respectively, independent of arterial pH. In contrast, bile acid secretion, 46 (41-59) mumol/min, was not changed by DCCD. The hepatic adenosine triphosphatase (ATP) level, 2.0 (1.8-2.1) mumol/g wet tissue, was not changed by DCCD. DCCD (10(-4) mol/l) affected neither Na,K-ATPase nor carbonic anhydrase activities in separate in vitro assay systems. The reduction in biliary HCO-3 secretion induced by the proton pump inhibitor DCCD may indicate that a proton pump is integrated into the mechanism responsible for secretin-dependent biliary secretion of HCO-3.

The response of the pancreas of the anaesthetized cat to secretin before, during and after reversible vagal blockade

Cooling the cervical vagi of the anaesthetized splanchnectomized cat to 2 degrees C caused a 54.4 +/- 8.8% inhibition of pancreatic electrolyte secretion stimulated submaximally with pure secretin. On rewarming the vagi there was a prolonged increase in secretion rate over and above the control rate which existed before cooling. The increase lasted about 90 min. There were no changes in acid/base status due to interference of the lung inflation reflex which could account for the inhibition of secretion and the subsequent rebound. Cold block of the cervical vagi increased the transpancreatic electrical conductance, indicating that vasodilation had occurred and therefore eliminated a vasomotor cause for the inhibition. Electrolyte secretion was also inhibited by bilateral vagal section. Atropine only partially prevented the inhibitory response to vagal cooling. A cholinergic mechanism, therefore, accounted for some but not all of the response to vagal cooling. It is concluded that even in the fasted, anaesthetized animal vagal impulses facilitate the action of secretin on the pancreas. This facilitation is only partially cholinergic; the major part of the response is due to some non-cholinergic transmitter substance. Such a mechanism may be necessary to potentiate the action of the very small amounts of secretin which appear to be released during a meal.

Mechanism of hepatic bicarbonate secretion and bile acid independent bile secretion

To examine hepatic bicarbonate transport and bile acid independent bile secretion, bile was sampled via a T-tube inserted into the common bile duct of anaesthetized pigs. Secretin was infused intravenously at a rate of 2.7 C.U./kg body weight h-1 (large dose) or 0.45 C.U./kg body weight h-1 (small dose). Hepatic water and electrolyte secretion were studied during systemic acid-base disturbances while secretin was continuously administered. Systemic acidosis reduced the rate of NaHCO3 secretion which fell in proportion to changes in plasma pH, by 9% and 2% per 0.1 pH unit for the large and small dose of secretin, respectively. Plasma pCO2 and bicarbonate concentration had little influence on NaHCO3 secretion. Consequently, plasma pH appeared to be the main determinant of hepatic NaHCO3 secretion during acid-base changes. Secretion of 1 mol NaHCO3 was accompanied by an isotonic solution containing water and 0.25 mol NaCl. After secretin infusion, 14C-erythritol clearance increased in proportion to bile flow. Bicarbonate secretion is determined by a gradient limited H+-pump at the contraluminal cell. During secretin stimulation bile acid independent bile secretion is osmotically driven by bile NaHCO3 flux.

Abolished relationship between pancreatic HCO-3 secretion and arterial pH during carbonic anhydrase inhibition

After acetazolamide administration, CO2 hydration in pancreatic cells would be slow and might become a rate-limiting factor to pancreatic HCO-3 secretion. Correspondingly, pancreatic HCO-3 secretion-normally pH dependent-would become slow and pH-independent. However, acetazolamide would not be expected to interfere with the capacity of the secretory mechanism to generate a proton potential gradient between pancreatic cells and interstitial fluid. These predictions were examined in 5 anesthetized, secretion infused (2.7 C. U./kg b.wt. h-1) pigs. Pancreatic juice was collected from a catheter in the pancreatic duct. Arterial pH was varied through i.v. HCl and NaHCO3 infusions and CO2 addition to inspired air. Before acetazolamide, HCO-3 secretion varied with plasma pH and averaged 298 +/- 30 mumol/min at control arterial pH. Acetazolamide (150 mg/kg, i.v.) reduced HCO3 secretion to 84 +/- 12 mumol/min and rendered secretion independent of arterial pH between pH 7.6 and pH 7.0. It is concluded that acetazolamide imposes a pH-independent transport maximum on pancreatic HCO-3 secretion, but does not reduce the capacity of the secretory mechanism to sustain a proton potential gradient between cells and interstitial fluid.

Pancreatic basal secretion in alcohol-fed and normal dogs

Biochemical, histological, and crystallographic studies were carried out on basal pancreatic secretion of 4 dogs fed alcohol for 12-15 months and 11 control dogs. The results in alcohol-fed dogs when compared to normals showed that: (1) protein concentration was higher, (2) fluid was decreased; (3) conductivity was decreased leading to differences in ionic distribution: Cl- and H+ ion concentrations increased, HCO3 concentrations and output decreased, total Ca, Mg, and Zn soluble in the juice did not change and therefore Ca, Mg, and Zn to protein ratios decreased. In the basal secretion of alcoholic dogs, numerous plugs were found of which three components were identified: (1) cells mostly of ductal origin; (2) calcium already crystallized; (3) protein material in the center of these plugs. Thus a change in Donan equilibrium led to modifications of protein and calcium solubilities with formation of precipitates. These findings are relevant to the study of chronic pancreatitis due to alcohol consumption.

Relationship between plasma pH and pancreatic HCO3- secretion at different intravenous secretin infusion rates

The relationship between pancreatic HCO3- secretion and plasma pH during acute systemic acid-base changes was investigated in 6 anesthetized, artificially ventilated pigs (20-25 kg) at 2 different, i.v. secretion infusion rates. At 0.45 C.U./kg b. wt. h-1 secretin infusion and plasma pH 7.40 +/- 0.01 pancreatic HCO3- secretion averaged 61+/- 12 mumol/min. Stepwise lowering of plasma pH through i.v. infusion of HCl and CO2 administration to inspired air proportionately reduced secretion rate; estimated zero HCO3- secretion occurring at plasma pH 7.01. Subsequent i.v. secretin infusion at 2.70 C.U./kg b. wt. h-1 increased HCO3- secretion to 249 +/- 42 mumol/min at plasma pH 7.33 + 0.04; stepwise lowering of plasma pH proportionately reduced HCO3- secretion to estimated zero at plasma pH 6.71. A reduction of plasma pH by 0.1 pH unit reduced HCO3- secretion during low and high rate of i.v. secretin infusion by 18 +/- 3 mumol/min and 35 +/- 8 mumol/min, respectively. Secretin infusion rate did not affect pancreatic chloride excretion. These findings support the view that secretin increases HCO3- secretion, and hence proton transport to the interstitial fluid, by augmenting the proton motive force developed by HCO3- secreting cells.

Differentiation between the calcium-dependent effects of cholecystokinin-pancreaozymin and the bicarbonate-dependent effects of secretin in exocrine secretion of the rat pancreas

1. Differentiation between the secretory effects of pure natural cholecystokinin-pancreozymin (CCK-PZ) and those of synthetic secretin was studied in the isolated pancreas of the rat perfused with a standard solution containing both Ca2+ and HCO2-, a Ca2+ deficient solution, or a HCO3-deficient solution. 2. Secretin induced a dose-dependent increase in the flow of pancreatic juice and a slight but definite increase in amylase output which was also dependent upon the dose of secretin. 3. The increase in the flow of pancreatic juice, induced by continuous stimulation with secretin (5 Ivy dog m-u./ml.), was completely abolished during perfusion with a CHO3- deficient solution, but was only slightly suppressed during perfusion with a Ca2+-deficient solution. 4. The increase in flow, induced by continuous stimulation with CCK-PZ (5 Ivy dog m-u./ml.), was partly affected by the deprivation of HCO3-, but was strongly inhibited by the deprivation of Ca2+. The CCK-PZ-induced amylase output was not affected by the deprivation of HCO3-, but was significantly inhibited by the deprivation of Ca2+. 5. The present results favour the view that CCK-PZ acts on the acinar cells to increase both amylase output and juice flow, whereas secretin acts on centro-acinar and terminal duct cells to increase mainly juice flow.

Respiratory exchanges and acid-base balance during perfusion of ex vivo isolated pancreas

We used the technique of ex vivo isolated pancreas, perfused with whole heparinized blood. The organ was stimulated by secretin (G.I.H. Stockolm, 0.1-5.0 clinic units/hr), and/or carbamylcholine (100-200 mug/hr). Oxygen consumption was increased under stimulation. This increase was a function of the dose of secretin and also of the bicarbonate output in the juice. Oxygen uptake increased further when carbamylcholine was super-imposed on secretin. This extra increase was independent of hemodynamic conditions of the organ perfusion. Arteriovenous difference in oxygen saturation did not increase when the gland was stimulated. It tended to decrease when the stimulation resulted in a marked vasodilatation. Thus, oxygen needs seemed to be neither the limiting factor of the response to a given stimulation nor the triggering mechanism of functional vasodilatation. Values of pCO2 were spread over a wide range from one experiment to another. However, it could be observed that CO2 efflux into the vein decreased under stimulation by secretin; in most experiments, CO2 efflux was even replaced by an apparent consumption of CO2 during the perfusion of the stimulated gland. Furthermore, arteriovenous pH difference increased following secretin stimulation. This increase was dose-related to secretin. These facts are discussed under the background of theories recently proposed for bicarbonate secretion.

The origin and secretion of pancreatic juice bicarbonate

1. The rate of secretion from a saline-perfused preparation of the cat's pancreas is directly proportional to the perfusate bicarbonate concentration. When all bicarbonate is omitted, secretion completely or almost completely ceases.2. Incorporation of [(14)C]bicarbonate into the perfusion fluid results in its prompt appearance in the juice. The radioactive label is concentrated four to five times in the juice just as the total juice bicarbonate is four to five times greater than perfusate bicarbonate.3. These two observations suggest that about 95% of pancreatic juice bicarbonate is derived from perfusate (plasma) bicarbonate.4. The inhibition of pancreatic secretion from the perfused gland by acetazolamide is similar to that observed in the intact animal.5. There is a fall in pH and rise in P(CO2) in the perfusion fluid leaving the gland which is greater during secretion than at rest.6. It is therefore suggested that during secretion, hydrogen ions pass from the gland into the perfusate (plasma), thus increasing the production of carbon dioxide from circulating bicarbonate. This carbon dioxide diffuses into the cell, is rehydrated (partly under the influence of carbonic anhydrase) and finally is secreted, thus establishing the necessary gradient for the continued diffusion of carbon dioxide into the cell.