Renal vascular response to salt restriction in normal man. Evidence against adrenergic mediation

Renal perfusion and function. The implications of converting enzyme inhibition

Because the kidney is both the source of circulating renin and the final determinant of the state of sodium balance, which in turn defines responsiveness to angiotensin II, one might have anticipated substantial interest in the impact of converting enzyme inhibitors on the kidney when these agents were developed. The lessons learned about the role of the renin-angiotensin system in normal renal perfusion and function, and possible disorders of control that contribute to disease in patients with essential hypertension, renovascular hypertension, and chronic progressive renal parenchymal disease are reviewed. In each case, the lessons here have important implications for the clinical application of converting enzyme inhibition.

Renal and systemic hemodynamics in sustained essential hypertension

Cardiac output (CO), renal blood flow (RBF), calf blood flow (CBF), and hepatic blood flow (HBF), glomerular filtration rate (GFR), and dopamine beta hydroxylase (D beta H) activity were studied in 198 men (67 normotensive controls and 131 hypertensive patients) of the same age with sustained uncomplicated essential hypertension. In the hypertensive men, the RBF and the RBF/CO ratio were significantly decreased (p less than 0.001). The RBF and RBF/CO ratio were negatively correlated with age (p less than 0.01), blood pressure (p less than 0.01), and D beta H activity (p less than 0.01). None of these relationships were observed with CBF and HBF. The observed decreases in RBF and the RBF/CO ratio in hypertensive men were reversed after administration of clonidine and alpha-methyldopa (p less than 0.01), but not after administration of propranolol. The study provides evidence that the reduction of renal perfusion in essential hypertension is partly reversible and related to an abnormality in the adrenergic system control.

Conceptual dilemmas in the classification of vasodilator drugs for severe chronic heart failure. Advocacy of a pragmatic approach to the selection of a therapeutic agent

Two distinct systems of classifying vasodilator drugs have been developed over the past decade in an attempt to guide the choice of a therapeutic agent for the patient with severe heart failure, but the merits and utility of these systems have not been critically evaluated. Vasodilator drugs may be categorized according to their peripheral site of action: an agent may exert its effects preferentially on systemic arteries, systemic veins, or on both circulations. However, changes in the peripheral circulation cannot be directly translated into an improvement in central hemodynamic variables; furthermore, immediate hemodynamic responses may not be predictive of long-term clinical efficacy. Hence, there is no evidence that characterization of patients into hemodynamic subsets determined by the findings of right heart catheterization improves the clinical outcome of vasodilator therapy in chronic heart failure. An alternative classification system groups vasodilator drugs according to their mechanism of action: an agent may possess direct vasodilating effects or may exert its actions via selective neurohumoral inhibition. However, attempts to identify patients who might be most responsive to neurohumoral antagonism by measuring plasma renin activity or circulating levels of catecholamines before treatment have not been successful in predicting the clinical responses to therapy. Because neither system of drug classification provides the clinician with useful therapeutic guidelines, patients with severe heart failure appear to be best managed using a pragmatic approach in which specific drugs that produce predictable therapeutic benefits with a low frequency of side effects are utilized preferentially. Among presently available vasodilator agents, only captopril and oral isosorbide dinitrate have been shown to produce consistent hemodynamic and clinical improvement with an acceptable degree of adverse reactions.

Effects of adrenoceptor agonists and antagonists on smooth muscle cells and neuromuscular transmission in the guinea-pig renal artery and vein

In the guinea-pig renal artery and vein, the membrane potential was -66.8 mV and -46.8 mV, the length constant 0.54 mm and 0.43 mm, and the time constant 240 ms and 98 ms, respectively. The maximum slope of the depolarization produced by a 10 fold increase [K]o was 46 mV in the renal artery and 39 mV in the renal vein. Noradrenaline (NA over 5 X 10(-7)M in the artery and over 10(-7)M in the vein) depolarized the membrane and slightly reduced the membrane resistance, assessed from relative changes in the amplitude of electrotonic potential. The action of NA was suppressed by prazosin in the artery but by yohimbine in the vein, i.e. the alpha 1-adrenoceptor is present in the extrajunctional muscle membrane in the renal artery while the alpha 2-adrenoceptor is present in the renal vein. Dopamine and isoprenaline did not modify the membrane properties. In the renal artery, repetitive perivascular nerve stimulation (0.1 ms, 50 Hz, 5 shocks) evoked excitatory junction potential (e.j.p.). Applications of guanethidine (10(-6) M) or tetrodotoxin (3 X 10(-7) M) abolished the generation of the e.j.p.. Low concentrations of phentolamine (5 X 10(-7) M), prazosin (10(-7) M) and yohimbine (5 X 10(-7) M) enhanced the e.j.p. amplitude, while high concentrations of phentolamine (10(-5) M) and prazosin (greater than 10(-5) M) reduced the amplitude of e.j.p.s. NA, dopamine and clonidine consistently suppressed the amplitude of e.j.ps, at any given concentration over 10(-7) M. Spontaneous generated miniature e.j.ps (m.e.j.ps) were recorded on rare occasions. Phentolamine and yohimbine both at 5 x 10(-7) M and prazosin 10(-7) M increased the appearance of m.e.j.ps. 5 In the renal vein, repetitive nerve stimulation failed to generate the e.j.p. Sympathetic innervation to this tissue seems to be sparse. 6 Specificity of innervation and adrenoceptors present on smooth muscle cells in both the renal artery and vein are discussed, and the presynaptic regulation ofNA release is compared with findings in other vascular tissues.

[The importance of changes in whole-body balance of sodium and noradrenaline in essential hypertension (author's transl)]

In 22 patients with essential hypertension plasma levels and urine excretions of sodium and noradrenaline were studied before, during and after long-term beta-blockade with pindolol. The relation between mean blood pressure and the quotient of sodium-/noradrenaline-excretion changed during treatment (placebo r=-0.34; pindolol r=+0.31). During placebo there existed a significant (p is less than 0.03) correlation between blood pressure and sodium-excretion which disappeared during beta-blockade. No correlation between blood pressure and noradrenaline was seen during placebo, whereas during beta-blockade a significant (p is less than 0.003) correlation was observed. In contrast to the placebo period there was a significant positive correlation between sodium- and noradrenaline-excretion during long-term treatment with pindolol. It is concluded that whole-body balance of sodium and noradrenaline is an important factor in essential hypertension.

Renal vascular response to interruption of the renin-angiotensin system in normal man

We assessed the role of the renin-angiotensin system in the response of the renal circulation to restriction of sodium intake in 38 normal patients. Both saralasin (10 to 30 ng/kg/min), an angiotensin antagonist, and SQ 20881 (30 to 300microgram/kg), a converting enzyme inhibitor, induced a dose-related increase in renal blood flow (xenon 133 washout) only when the resin-angiotension system was activated by restriction of sodium intake to 10 MEq/day. Increasing doses of saralasin (100 to 1,000 ng/kg/min) reduced renal blood flow, presumably due to the angiotensin-like action of this partial agonist. The renal vascular response to SQ 20881 paralleled the endocrine response: An identical threshold dose (30 microgram/kg) increased renal blood flow and reduced plasma angiotensin II concentration, which fell despite a progressive rise of plasma renin activity. Plasma bradykinin concentration did not change in response to SQ 20881, which also blocks kininase II. Both agents also induced a small but consistent and statistically significant reduction in arterial blood pressure, which will be important in assessing the pathogenetic significance of a blood pressure reduction in patients with hypertension. This study indicates that angiotensin mediates the renal vascular response to restriction of salt intake in normal man and provides an approach to assessing the role played by angiotensin in the pathogenesis of functional renal disease.