Development of water transport in the collecting duct

Perioperative anesthetic management of premature neonates weighing less than 1500 grams undergoing transcatheter PDA (TC-PDA) closure: An institutional anesthetic experience

Objectives

The aim of our study is to describe the various anesthetic techniques and intraoperative management used during transcatheter closure of hemodynamically significant PDAs in VLBW premature infants weighing less than 1.5 kg and their potential impact on postoperative outcomes using a retrospective chart review.

Design

A retrospective electronic medical chart review was performed in infants who underwent Transcatheter Patent Ductus Arteriosus (TC-PDA) closure at an academic institution between January 1, 2008 and October 4th 2019. Only premature patients with isolated PDA weighing less than 1500 g at the time of the procedure were included in the study.

Setting

Single Institutional Hospital.

Participants

Premature patients with isolated PDA weighing less than 1500 g at the time of the procedure.

Interventions

None.

Measurements and main results

Interprocedurally, there was no evidence of device embolization or clinically significant vascular obstruction on follow-up echocardiography, and inotropic or vasoactive infusions were not required. All patients survived and were discharged from the hospital after a mean of 86.4 ± 48.49 days (median 74, range 40-180) following initial admission to the NICU. At 7 post-operative days, freedom from ventilatory support reached 70% in all patients. Incidences of device embolization or clinically significant vascular obstruction were not noted on follow-up echocardiography.

Conclusions

Though our preliminary findings show promising outcomes following TC-PDA closure relative to traditional surgical approaches, further investigations with higher patient volume are needed to validate these promising observations.

Fluid and Electrolyte Management in the Neonate: Sodium and Chloride

Maintenance of electrolyte balance in the neonate is a challenge in the context of illness or prematurity. Neonatal providers' approach to fluid management changes and adapts based on the newborn's age, maintenance needs, deficits, and ongoing losses. Understanding the total body water content of the fetus and newborn is foundational to management of electrolyte disturbances. This article reviews common imbalances of sodium and chloride, identifies causes of imbalances, and discusses current evidence-based treatment options.

Hyponatraemia despite isotonic maintenance fluid therapy: a time series intervention study

OBJECTIVE

To examine the prevalence of dysnatraemias among children admitted for paediatric surgery before and after a change from hypotonic to isotonic intravenous maintenance fluid therapy.

DESIGN

Retrospective consecutive time series intervention study.

SETTING

Paediatric surgery ward at the Children's Hospital in Lund, during a 7-year period, 2010-2017.

PATIENTS

All children with a blood sodium concentration measurement during the study period were included. Hypotonic maintenance fluid (40 mmol/L NaCl and 20 mmol/L KCl) was used during the first 3 years of the study (646 patients), and isotonic solution (140 mmol/L NaCl and 20 mmol/L KCl) was used during the following period (807 patients).

MAIN OUTCOME MEASURES

Primary outcomes were sodium concentration and occurrence of hyponatraemia (<135 mmol/L) or hypernatraemia (>145 mmol/L).

RESULTS

Overall, the change from hypotonic to isotonic intravenous maintenance fluid therapy was associated with a decreased prevalence of hyponatraemia from 29% to 22% (adjusted OR 0.65 (0.51-0.82)) without a significantly increased odds for hypernatraemia (from 3.4% to 4.3%, adjusted OR 1.2 (0.71-2.1)). Hyponatraemia <130 mmol/L decreased from 6.2% to 2.6%, and hyponatraemia <125 mmol/L decreased from 2.0% to 0.5%.

CONCLUSIONS

Routine use of intravenous isotonic maintenance fluids was associated with lower prevalence of hyponatraemia, although hyponatraemia still occurred in over 20% of patients. We propose that the composition and the volume of administered fluid need to be addressed.

Osmoregulation Performance and Kidney Transplant Outcome

BACKGROUND

Kidney transplant recipients have an impaired ability to dilute urine but seldom develop baseline hyponatremia before ESRD. Although hyponatremia is a risk factor for adverse events in CKD and in kidney transplant recipients, it remains unclear whether subtler alterations in osmoregulation performance are associated with outcome.

METHODS

We studied a single-center prospective cohort of 1258 kidney transplant recipients who underwent a water-loading test 3 months after transplant to determine osmoregulation performance. Measured GFR (mGFR) was performed at the same visit. A group of 164 healthy candidates for kidney donation served as controls. We further evaluated the association of osmoregulation performance with transplantation outcomes and subsequent kidney function.

RESULTS

Unlike controls, most kidney transplant recipients failed to maintain plasma sodium during water loading (plasma sodium slope of -0.6±0.4 mmol/L per hour in transplant recipients versus -0.12±0.3 mmol/L per hour in controls; P<0.001). Steeper plasma sodium reduction during the test independently associated with the composite outcome of all-cause mortality and allograft loss (hazard ratio [HR], 1.73 per 1 mmol/L per hour decrease in plasma sodium; 95% confidence interval [95% CI], 1.23 to 2.45; P=0.002) and allograft loss alone (HR, 2.04 per 1 mmol/L per hour decrease in plasma sodium; 95% CI, 1.19 to 3.51; P=0.01). The association remained significant in a prespecified sensitivity analysis excluding patients with hyperglycemia. In addition, a steeper plasma sodium slope 3 months after transplantation independently correlated with lower mGFR at 12 months (β=1.93; 95% CI, 0.46 to 3.41; P=0.01).

CONCLUSIONS

Reduced osmoregulation performance occurs frequently in kidney transplant recipients and is an independent predictor of renal outcome.

Prostaglandin-E2 Mediated Increase in Calcium and Phosphate Excretion in a Mouse Model of Distal Nephron Salt Wasting

Contribution of salt wasting and volume depletion to the pathogenesis of hypercalciuria and hyperphosphaturia is poorly understood. Pendrin/NCC double KO (pendrin/NCC-dKO) mice display severe salt wasting under basal conditions and develop profound volume depletion, prerenal renal failure, and metabolic alkalosis and are growth retarded. Microscopic examination of the kidneys of pendrin/NCC-dKO mice revealed the presence of calcium phosphate deposits in the medullary collecting ducts, along with increased urinary calcium and phosphate excretion. Confirmatory studies revealed decreases in the expression levels of sodium phosphate transporter-2 isoforms a and c, increases in the expression of cytochrome p450 family 4a isotypes 12 a and b, as well as prostaglandin E synthase 1, and cyclooxygenases 1 and 2. Pendrin/NCC-dKO animals also had a significant increase in urinary prostaglandin E2 (PGE-2) and renal content of 20-hydroxyeicosatetraenoic acid (20-HETE) levels. Pendrin/NCC-dKO animals exhibit reduced expression levels of the sodium/potassium/2chloride co-transporter 2 (NKCC2) in their medullary thick ascending limb. Further assessment of the renal expression of NKCC2 isoforms by quantitative real time PCR (qRT-PCR) reveled that compared to WT mice, the expression of NKCC2 isotype F was significantly reduced in pendrin/NCC-dKO mice. Provision of a high salt diet to rectify volume depletion or inhibition of PGE-2 synthesis by indomethacin, but not inhibition of 20-HETE generation by HET0016, significantly improved hypercalciuria and salt wasting in pendrin/NCC dKO mice. Both high salt diet and indomethacin treatment also corrected the alterations in NKCC2 isotype expression in pendrin/NCC-dKO mice. We propose that severe salt wasting and volume depletion, irrespective of the primary originating nephron segment, can secondarily impair the reabsorption of salt and calcium in the thick ascending limb of Henle and/or proximal tubule, and reabsorption of sodium and phosphate in the proximal tubule via processes that are mediated by PGE-2.

Aquaporin 2: Identification and analysis of expression in calves’ urine during their first month of life

Michałek, K., Dratwa-Chałupnik, A., Ciechanowicz, A. K. and Malinowski, E. 2014. Aquaporin 2: Identification and analysis of expression in calves’ urine during their first month of life. Can. J. Anim. Sci. 94: 653–659. Aquaporin 2 (AQP2) is a vasopressin-regulated water channel of the renal collecting duct and is excreted into urine. Renal excretion of AQP2 has been studied in humans, dogs, rats and mice. The aim of this study was to identify and analyze expression of AQP2 in calves’ urine. Short and controlled diarrhea was induced in the calves in order to determine any change in renal excretion of AQP2 and to evaluate a possible role of this channel in water balance during the neonatal period. For this purpose, an additional portion of lactose was administered to the calves with a milk replacer. The present work shows that after transient diarrhea associated with excessive supply of lactose in the diet, a significant increase in renal AQP2 excretion was reported in the first 3 wk of the calves’ lives. Renal excretion of this protein in the urine increased significantly despite the absence of changes in the concentration of vasopressin or the osmotic pressure of the blood plasma. The increase observed in the expression of the protein might be associated with the reduction of the total Ca2+ concentration in the blood plasma of calves. The results clearly indicate a different mechanism regulating urinary excretion of AQP2 in newborn calves, hitherto unknown. Although elevated renal excretion of AQP2 was observed, there was no increase in the osmolality of the urine in the calves tested.

Decreased serum osmolality promotes ductus arteriosus constriction

AIMS

At birth, dynamic changes occur in serum components and haemodynamics, such as closure of the ductus arteriosus (DA). A previous study demonstrated that, in full-term human neonates, serum osmolality decreased transiently after birth, but recovered over the next few days. However, the significance of this transient decrease in osmolality has never been addressed. The objective of the present study was to examine the role of changes in serum osmolality after birth in DA closure.

METHODS AND RESULTS

We found that rats exhibited a similar transient hypoosmolality after birth. Hypotonic stimulation induced constriction of DA rings and increased Ca(2+) transient in DA smooth muscle cells, but not in the aorta. The hypoosmotic sensor transient receptor potential melastatin 3 (TRPM3) was highly expressed in the rat DA, and TRPM3 silencing abolished the Ca(2+) response to hypoosmolality. Pregnenolone sulfate stimulation of TRPM3 induced rat DA constriction ex vivo and in vivo. Furthermore, hypertonic fluid injection impaired rat DA closure. In humans, neonatal serum hypoosmolality was observed in relatively mature preterm infants (≥28 weeks). In extremely preterm infants (<28 weeks), however, this hypoosmolality was absent. Instead, a rapid increase in osmolality occurred thereafter. Such an increase was greater, in particular, among patent DA (PDA) patients.

CONCLUSIONS

A transient decrease in serum osmolality may promote DA closure during the first few days of life. Adjusting serum osmolality to proper levels might help to prevent the onset of PDA, improving the therapeutic outcome in extremely preterm infants.

Aquaporins in avian kidneys: function and perspectives

For terrestrial vertebrates, water economy is a prerequisite for survival, and the kidney is their major osmoregulatory organ. Birds are the only vertebrates other than mammals that can concentrate urine in adaptation to terrestrial environments. Aquaporin (AQP) and glyceroporin (GLP) are phylogenetically old molecules and have been found in plants, microbial organisms, invertebrates, and vertebrates. Currently, 13 AQPs/aquaGLPs and isoforms are known to be present in mammals. AQPs 1, 2, 3, 4, 6, 7, 8, and 11 are expressed in the kidney; of these, AQPs 1, 2, 3, 4, and 7 are shown to be involved in fluid homeostasis. In avian kidneys, AQPs 1, 2, 3, and 4 have been identified and characterized. Also, gene and/or amino acid sequences of AQP5, AQP7, AQP8, AQP9, AQP11, and AQP12 have been reported in birds. AQPs 2 and 3 are expressed along cortical and medullary collecting ducts (CDs) and are responsible, respectively, for the water inflow and outflow of CD epithelial cells. While AQP4 plays an important role in water exit in the CD of mammalian kidneys, it is unlikely to participate in water outflow in avian CDs. This review summarizes current knowledge on structure and function of avian AQPs and compares them to those in mammalian and nonmammalian vertebrates. Also, we aim to provide input into, and perspectives on, the role of renal AQPs in body water homeostasis during ontogenic and phylogenetic advancement.

Salvia miltiorrhiza reduces expression of aquaporin 2 in kidney tissue of cirrhotic rats

AIM: To detect the expression of aquaporin 2 (AQP2) in kidney tissue of rats with BDL-induced cirrhosis and to observe the effect of treatment with salvia miltiorrhiza on AQP2 expression in this animal model.

METHODS: Seventy SD rats were randomly divided into sham operation group and model group. To induce biliary cirrhosis, SD rats underwent double ligation and sectioning of the common bile duct (BDL). Animals in the model group were sacrificed at weeks 1, 2, 3 and 4. At week 5, the model group was divided into two groups: treatment group and control group. Rats in the treatment group were treated with salvia miltiorrhiza, while those in the control group was treated with vehicle. Liver histopathological changes were evaluated by hematoxylin and eosin (H&E) staining and Masson's trichrome staining. Kidney histopathological changes were evaluated by H&E staining. Immunohistochemistry was employed to investigate the expression of AQP2 in kidney tissue of cirrhotic rats.

RESULTS: With the progression of hepatic cirrhosis, the expression of AQP2 increased gradually. The optical density (OD) of renal AQP2 at weeks 1 to 4 was significantly higher in the model group than in the sham operation group (cortex: 0.4703 ± 0.0313, 0.4832 ± 0.0212, 0.5081 ± 0.0417, 0.6802 ± 0.0531 vs 0.4197 ± 0.0295; medulla: 0.4320 ± 0.0237, 0.4724 ± 0.0284, 0.4796 ± 0.0451, 0.5187 ± 0.0612 vs 0.4139 ± 0.0152; all P < 0.05). The expression of AQP2 in the control group was higher than that in the treatment group. The OD of renal AQP2 in the control group was significantly higher than that in the treatment group (cortex: 0.5536 ± 0.0476 vs 0.4233 ± 0.0521; medulla: 0.4764 ± 0.0536 vs 0.4158 ± 0.0413, both P < 0.05).

CONCLUSION: The expression of AQP2 is up-regulated in kidney tissue of cirrhotic rats. Salvia miltiorrhiza treatment reduced the expression of AQP2 in kidney tissue of cirrhotic rats.

Aquaporin-2 urinary excretion in preterm infants: relationship to diuresis and vasopressin

AIMS

Few investigations have explored the urinary aquaporin-2 (u-AQP2) excretion pattern after birth in preterm infants with conflicting results regarding the correlation between u-AQP2, urinary osmolality and vasopressin. The aims of this study were to evaluate u-AQP2 excretion during the first week of life in preterm infants, to correlate u-AQP2 with other markers of renal function and to investigate the relationship between u-AQP2, urinary tonicity and arginine-vasopressin in the immature kidney.

METHODS

In infants born less than 33 weeks daily diuresis, u-AQP2, urinary arginine-vasopressin, urine and plasma tonicity, creatinine and electrolytes were measured through the first 7 days of life.

RESULTS

Fifty-five infants were evaluated. u-AQP2 excretion showed the following profile: the highest u-AQP2 levels were found on day 2 and values remained significantly higher until day 5 with respect to day 1. On day 6, u-AQP2 levels significantly decreased to values closer to those found on day 1. u-AQP2 excretion was not associated with arginine-vasopressin while significant, but weak association was found with urinary tonicity (r = -0.20; -0.32 < r < -0.11; P < 0.05). u-AQP2 excretion and creatinine clearance were significantly associated during the study period (r = 0.19; 0.08 < r < 0.29; P < 0.05). There was a strong association between totally u-AQP2 excretion and diuresis over the week (r = 0.72; 0.66 < r < 0.76; P < 0.0001).

CONCLUSION

Significant variations occur in AQP2 expression levels during the first week of life in preterm infants. AQP2 does not seem to contribute to the urinary concentration ability after birth. Further investigations are required to elucidate the mechanisms underlying the strong association between diuresis and u-AQP2 excretion in early postnatal life.

Using enteral sterile water feeds for hypernatremia in extremely low birth-weight infants

Extremely low birth-weight infants are prone to fluid and electrolyte imbalance due to multiple etiologies. Hypernatremia can occur in this gestational age group during the first week of life. One therapy that many NICUs initiate to treat hypernatremia is enteral sterile water feeds (SWFs). The use of free water is an adjunct therapy in place of large volumes of intravenous fluids. This article presents a review of renal physiology and 3 case studies of infants, less than 27 weeks' gestational age and less than 1000-g birth weight, treated with SWFs for hypernatremia. Commonalities and differences in treatment are addressed. There is limited evidence-based research using enteral SWFs for the treatment of hypernatremia.

Physiological partial aldosterone resistance in human newborns

In the neonatal period, the human kidney is characterized by an impaired ability to regulate water and sodium homeostasis, resembling partial aldosterone resistance. The aim of our study was to assess this hormonal insensitivity in newborn infants and to determine its relationship with neonatal sodium handling. We conducted a prospective study in 48 healthy newborns and their mothers. Aldosterone, renin, and electrolyte concentrations were measured in umbilical cords and in maternal plasma. Urinary aldosterone concentrations and sodium excretion were determined at urination within 24 h after birth. A significant difference was observed between aldosterone and renin levels in newborn infants compared with their mothers (817 +/- 73 versus 575 +/- 55 pg/mL and 79 +/- 10 versus 15 +/- 2 pg/mL, respectively, p < 0.001). This hyperactivation of the renin-angiotensin-aldosterone system was associated with hyponatremia and hyperkalemia in the newborn infants, and high urinary sodium loss, consistent with a partial aldosterone resistance at birth. Unlike plasma aldosterone, urinary aldosterone concentration was found highly correlated with plasma potassium concentrations, thus representing the best index for accurate evaluation of mineralocorticoid sensitivity. Our study represents a comprehensive characterization of the renin-aldosterone axis in newborn infants and provides evidence for physiologic partial aldosterone resistance in the neonatal period.

Postnatal developmental renal physiology: a study of historic significance

This essay looks at the historic significance of an APS classic paper ( http://www.the-aps.org/publications/classics/ ) that is freely available online:

Falk G. Maturation of renal function in infant rats. Am J Physiol 181: 157–170, 1955 ( http://ajplegacy.physiology.org/cgi/reprint/181/1/157 ).

Antenatal Bartter's syndrome: why is this not a lethal condition?

There are four themes in this teaching exercise for Professor McCance. The first challenge was to explain how a premature infant with Bartter's syndrome could survive despite having such a severe degree of renal salt wasting. Second, the medical team wanted to know why there was such a dramatic decrease in the natriuresis in response to therapy, despite the presence of a permanent molecular defect that affected the loop of Henle. Third, Professor McCance was asked why this patient seemed to have a second rare disease, AQP2 deficiency type of nephrogenic diabetes insipidus. The fourth challenge was to develop a diagnostic test to help the parents of this baby titrate the dose of indomethacin to ensure an effective dose while minimizing the likelihood of developing nephrotoxicity. The missing links in this interesting story emerge during a discussion between the medical team and its mentor.

Urine concentration and avian aquaporin water channels

Although birds and mammals have evolved from primitive tetrapods and advanced divergently, both can conserve water by producing hyperosmotic urine. Unique aspects in the avian system include the presence of loopless and looped nephrons, lack of the thin ascending limb of Henle's loop, a corticomedullary osmotic gradient primarily consisting of NaCl without contribution of urea, and significant postrenal modification of final urine. The countercurrent multiplier mechanism operates between the descending and ascending limbs of Henle via recycling of a single solute (NaCl) with no water accompaniment, forming an osmotic gradient along the medullary cone. Bird kidneys and developing rat kidneys share morphological and functional characteristics. Avian kidneys express aquaporin (AQP) 1, 2, and 4 homologues that share considerable homology with mammalian counterparts, but their distribution and function may not be the same. AQP2 expression in Japanese quail (q) evolves in the collecting duct of early metanephric kidneys and continues to increase in intensity and distribution during nephrogenesis and maturation. qAQP2 mRNA and protein are increased by arginine vasotocin (avian ADH), but vasotocin-induced enhancement of cAMP production and water permeability are less marked than in mammalian kidneys. Nephrogenesis is delayed by insufficient nutrition in avian embryos and newborns and results in fewer nephrons and an impaired water balance in adults. Diabetes insipidus quail with homozygous autosomal recessive mutation and an unaffected vasotocin system have low AQP2 expression, underdeveloped medullary cones. Comparative studies will provide important insight into integrative, cellular, and molecular mechanisms of epithelial water transport and its control by humoral, neural, and hemodynamic mechanisms.

Aquaporin-2 water channel in developing quail kidney: possible role in programming adult fluid homeostasis

Avian kidneys have loopless and looped nephrons; a countercurrent multiplier mechanism operates in the latter by NaCl recycling. We identified an aquaporin-2 (AQP2) homolog in apical/subapical regions of cortical and medullary collecting duct (CD) cells in kidneys of Japanese quail (q), Coturnix japonica. We investigated whether undernutrition during the embryonic/maturation period retards kidney and AQP2 development in quail and programs impaired volume regulation in adults. Protocols included 1) time course and 2) effects of 5-10% egg white withdrawal (EwW) or 48-h post-hatch food deprivation (FD) on nephron growth and qAQP2 mRNA expression, and 3) effects of EwW and FD on qAQP2 mRNA responses to 72-h water deprivation in adults. In metanephric kidneys, qAQP2 mRNA is expressed in medullary CDs at embryonic day 10; distribution and intensity increase during maturation. The number and size of glomeruli continue to increase after birth, whereas nephrogenic zones decrease. In EwW embryos, qAQP2 mRNA expression is initially delayed, then restored; birth weight and hatching rate are lower than in controls. Adults from EwW embryos and FD chicks have fewer (P < 0.01) glomeruli. Water deprivation reduces body weight more in EwW birds than in controls. The results suggest that qAQP2 evolved in metanephric kidneys and that undernutrition may retard nephrogenesis, leading to impaired adult water homeostasis.

Nephrogenic syndrome of inappropriate antidiuresis in adults: high phenotypic variability in men and women from a large pedigree

Nephrogenic syndrome of inappropriate antidiuresis (NSIAD) is a recently described genetic cause of hyponatremia in male infants. Whether this X-linked condition could be detected in the adult or also could affect women is unknown. A large five-generation family was identified in which the recently described arginine-vasopressin receptor type 2 (AVPR2) mutation that is responsible for NSIAD was segregated. The proband was a 74-yr-old patient who had a syndrome of inappropriate antidiuresis and whose hyponatremia resisted administration of two AVPR2 antagonists. The phenotype of family members who carry the mutation was investigated. Patients with normal serum sodium were subjected to a water-load test. The previously reported activating missense R137C mutation in the AVPR2 gene in three hemizygous male and four heterozygous female individuals was identified. Except in one woman, spontaneous episodes of hyponatremia or abnormal water-load test were identified in all patients with the mutation, whether male or female. Skewed X inactivation was evidenced in the blood of the asymptomatic woman, which is compatible with preferential inactivation of her mutated allele. NSIAD is not limited to male infants. The diagnosis also should be considered in both male and female adults.

Urinary aquaporin-2 excretion during early human development

This study was undertaken to assess one of the determinants of kidney concentrating capacity, aquaporin-2 (AQP2), in order to understand the physiopathology of water balance in newborn babies. Urinary AQP2 excretion has been shown to be proportional to AQP2 level in the apical plasma membrane of the kidney collecting ducts and has been suggested as a marker of vasopressin (AVP) action. Urinary AQP2 excretion in the early postnatal period and at 3 weeks of age was measured in 123 neonates admitted during a 6-month period to the neonatal intensive care unit of the Children's Hospital of Toulouse, France. Clinical and biochemical data were collected for each child. During the first days after birth, higher urinary AQP2 was observed in boys than in girls (P=0.01) and positively correlated with urinary sodium/potassium (Na/K) ratio (r=0.33, P=0.01). When the babies had reached 3 weeks of age, urinary AQP2 was proportional to the gestational age at birth (r=0.33, P=0.0068) and daily weight gain (r=0.36, P=0.003). It did not correlate with urinary osmolality, which was overall very low in all babies. Urinary AQP2 was decreased in conditions of impaired renal function (r=-0.42, P=0.0005) and acidosis (P=0.03). Prenatal corticosteroid treatment had no significant impact on urinary AQP2 level. Our data show that urinary AQP2 correlates with the overall maturity of tubular function in human neonates. In babies at this early age, urinary AQP2 cannot serve as a direct marker of the renal action of AVP but reflects AQP2 expression level associated with different physiopathological conditions.