Role of the autonomic nervous system in the renal vasoconstriction response to hemorrhage in the rabbit

Acute Decompensated Heart Failure in Patients with Heart Failure with Reduced Ejection Fraction

Acute decompensated heart failure (ADHF) requires immediate treatments because it impairs perfusion to systemic organs and their function. Half of all patients with ADHF are diagnosed with heart failure with reduced left ventricular ejection fraction (HFrEF). The initial goal of management for ADHF is to stabilize hemodynamic status. Pulmonary edema is treated with vasodilators or diuretics. Inhibitors of the renin-angiotensin-aldosterone system and β-blockers should be started and/or increased to meet the maximum dose, ideally the target dose, that the patient can tolerate as a treatment of HFrEF. Patients with severe circulatory failure need inotropic drugs or mechanical circulatory support.

Noradrenaline: friend or foe?

Septic shock, systemic inflammation and pharmacological vasodilatation are often complicated by systemic hypotension despite aggressive fluid resuscitation and an increased cardiac output. If the physician wishes to restore arterial pressure to higher levels (> 80-85 mmHg), with the aim of sustaining cerebral and coronary perfusion pressure, the administration of systemic vasopressor agents, such as norepinephrine (noradrenaline), becomes necessary. However, because norepinephrine (NE) induces vasoconstriction in many vascular beds (visibly in the skin), it may decrease renal and visceral blood flow, impairing visceral organ function. This unproven fear deters clinicians from using NE more consistently. Vasodilated states, however, are often associated with impaired peripheral vascular responsiveness. In such states, unlike under normal circulatory conditions, NE may actually improve visceral organ blood flow by selectively increasing organ perfusion pressure. Data available from animal studies show that the increased organ perfusion pressures achieved with NE results in improved GFR and renal blood flow. In fact, recent sophisticated physiological analysis of its effects on the kidney shows that, even after controlling for the pressure effect, NE therapy is associated with an increase in renal blood flow after endotoxin administration. In particular, the renal Pzf (pressure at which there is no further blood flow) is decreased such that, at a constant pressure, renal blood flow increases after NE. There are no controlled human data to define the effects of NE on the kidney in the clinical context. However, many patient series have now been reported. They show a seemingly positive effect of NE administration on GFR and urine output. Our clinical experience in septic patients and cardiac patients with inflammatory or pharmacological vasodilatation is also positive. We have demonstrated a positive effect on coronary blood flow. There is no reason to fear the effect of NE. If it is used to support a vasodilated circulation after adequate intravascular filling has occurred and after a normal or increased cardiac output has been established, it is likely to be a friend not a foe.

Renal sympathetic nerves modulate erythropoietin plasma levels after transient hemorrhage in rats

In contrast to other sympathetic outflow tracts, renal sympathetic nerve activity (RSNA) decreases in response to hypotensive hemorrhage. The functional significance of this "paradox" is not known. We tested the hypothesis that RSNA modulates renal perfusion and thus erythropoietin (EPO) release after transient hypotensive hemorrhage in anesthetized rats. Plasma EPO was measured before and after 30 min of transient hypotensive hemorrhage (i.e., -40 mmHg from mean baseline blood pressure, followed by reinfusion of shed blood) and 120 min thereafter in sham-denervated rats, and after renal denervation (DNX) or bilateral cervical vagotomy (VX) to abolish/blunt the RSNA decrease mediated by a cardiopulmonary reflex. RSNA, renal Doppler flow, renal vascular resistance (RVR), resistance index, and oxygen delivery/uptake (Do(2)/Vo(2)) were measured. RSNA decreased in intact animals (-40 +/- 5% from baseline, P < 0.05). This was blunted by VX. With intact nerves, EPO level did not increase. In DNX rats, EPO was increased at minute 120 (49 +/- 3 vs. 74 +/- 2 mU/ml; P < 0.05), in VX rats this (47 +/- 2 vs. 62 +/- 4 mU/ml; P < 0.05) was less pronounced. Do(2) in DNX rats was lower compared with intact and VX rats (0.25 +/- 0.04 vs. 0.51 +/- 0.06 and 0.54 +/- 0.05 ml O(2)/min; P < 0.05) due to lower Doppler flow and increased RVR. RVR and Do(2) were similar in intact and VX rats, but resistance index differed between all groups (0.70 +/- 0.02 vs. 0.78 +/- 0.02 vs. 0.85 +/- 0.02; P < 0.05, intact vs. VX vs. DNX), indicating differential reactivity of renal vasculature. Vo(2) was unaffected by VX and DNX. Renal sympathoinhibition during hypotensive hemorrhage might help to preserve sufficient oxygenation of renal tissue by modulation of hemodynamic mechanisms that act to adapt renal oxygen availability to demand.

Sepsis and the Kidney

Acute renal failure (ARF) secondary to sepsis is a highly prevalent diagnosis in the ICU setting and continues to be associated with a high rate of morbidity and mortality. The pathophysiology of sepsis-induced acute renal failure involves ischemic or toxic injury to the renal tubular epithelia, resulting in necrosis or apoptosis, and clinically is characterized as acute tubular necrosis. The management of sepsis-induced ARF includes both conventional intermittent hemodialysis and continuous renal replacement therapies. Experimental therapies to improve outcomes in sepsis-associated ARF include the provision of plasmapheresis and adsorption therapies, and the recent development and deployment of a renal tubule assist device.

Effects of norepinephrine on the renal vasculature in normal and endotoxemic dogs

Septic shock is often complicated by systemic hypotension despite normal or increased cardiac output. Restoration of arterial pressure usually requires the administration of systemic vasopressor agents, such as norepinephrine. However, because norepinephrine induces vasoconstriction in other vascular beds, it may decrease visceral blood flow, impairing visceral organ function. Because sepsis is often associated with impaired peripheral vascular responsiveness, we hypothesized that, unlike in normal circulatory conditions, norepinephrine would improve visceral organ blood flow in sepsis by selectively increasing organ perfusion pressure. Thus, in nine pentobarbital-anesthetized, mechanically ventilated dogs, we measured the effect of norepinephrine infusion (0.3 microgram/kg/min) on renal, hepatic, and portal steady-state pressure-flow relations (P/Q) and the dynamic vascular P/Q, created by transient inferior vena caval occlusion, under basal and endotoxic conditions. Norepinephrine increased organ perfusion pressures during both control and endotoxemic conditions. However, even after controlling for the pressure effect using a general linear model, NE was associated with an increase in renal blood flow both before and after endotoxin administration. We conclude that, unlike the effects of administering norepinephrine under baseline conditions, norepinephrine infusion during endotoxic shock actually increases renal blood flow and that this effect is not the result of an increase in perfusion pressure alone.

Human cardiovascular adjustments to acute hypoxaemia

Traditionally, cardiovascular adjustments to hypoxaemia are viewed as resultants of competing local vasodilation and vasoconstriction via arterial chemoreflexes with net effects of increased cerebral and coronary blood flows (local) and reduced flow to visceral organs and muscle (reflex). Although true in asphyxia, breathing activates lung mechanoreceptors which reduce vagal outflow and apparently, in humans, abolishes sympathetic vasomotor activity (SNA). During rest, moderate to severe hypoxaemia (PaO2 = 35 to 27 mmHg) caused no splanchnic, cutaneous or muscle vasoconstriction. Local vasodilator effects of hypoxaemia were not sufficient to overwhelm vasoconstriction; splanchnic arterioles responded normally to infused noradrenalin (NA) during hypoxaemia. Possibly, central effects of hypoxaemia blunt SNA or peripheral, prejunctional effects impair neuronal release of NA. Persistent orthostatic tolerance with normal skeletal muscle vasoconstriction and retained spinal venomotor reflexes during hypoxaemia argue against prejunctional inhibition of NA release. Results so far suggest that beyond a certain threshold, hypoxaemia centrally inhibits SNA. In contrast to rest, even moderate hypoxaemia during exercise markedly increases plasma NA concentration (and SNA), but the usual relationship among splanchnic blood flow, plasma NA and heart rate was not observed--NA and heart rate rose together, whereas the predicted splanchnic vasoconstriction was not observed. In moderate hypoxaemia, muscle blood flow and cardiac output are greater than in normoxia at a given submaximal oxygen uptake; but at maximal oxygen uptake, blood pressure, total vascular conductance and maximal cardiac output are unaffected. Given the fixed upper limit to cardiac output and the greater capacity of active muscle to vasodilate and exceed cardiac pumping capacity during hypoxaemia, we conclude that blood pressure is maintained by baroreflex- (not chemoreflex-) mediated vasoconstriction in the active muscle which must be the primary target of increased SNA and the source of NA.

Rostral pontine and caudal mesencephalic control of arterial pressure and iliac, celiac and renal vascular resistance. II. Separate control and topographic organization

A dense mapping of the rostral pons and caudal mesencephalon was performed in 26 cats using electrical stimulation while measuring arterial pressure and iliac, celiac and renal vascular resistance to determine if these vascular beds are controlled separately. It was found that the central tegmental fields (CTF) of the mesencephalon contained a large area active in control of iliac vascular resistance and a smaller area active in control of renal vascular resistance. It was found that the marginal nucleus of the brachium conjunctivum (BCM) contained areas active in control of all three vascular beds studied. To determine if the BCM controlled regional vascular beds differently, the relationship between changes in vascular resistance in each bed and changes in arterial pressure were examined quantitiatively using regression analysis and the slopes of the regression lines were shown to be different (P less than 0.001). Further analysis of the relationships of changes in vascular resistance of pairs of vascular beds indicated that vascular beds are controlled differently in response to electrical stimulation of the BCM.

Prostaglandins and the renal responses to haemorrhage, angiotensin II and methoxamine in conscious rabbits

The responses to 20% haemorrhage were examined in conscious rabbits with or without inhibition of prostaglandin production by indomethacin (5 mg/kg + 0.5 mg/kg per h i.v.). In rabbits not pretreated with indomethacin, haemorrhage lowered mean arterial pressure by 6.3 (s.e.m. = 1.6) mmHg, renal blood flow by 22.8 (s.e.m. = 3.4) ml/min and glomerular filtration rate (GFR) by 3.4 (s.e.m. = 0.6) ml/min, and raised plasma renin activity by 5.2 (s.e.m. = 1.0) ng/ml per h. Pretreatment of the rabbits with indomethacin did not significantly alter the responses to haemorrhage. Mean arterial pressure fell by 10.9 (s.e.m. = 1.8) mmHg, renal blood flow by 24.9 (s.e.m. = 3.9) ml/min and GFR by 4.2 (s.e.m. = 1.8) ml/min and plasma renin activity rose by 3.2 (s.e.m. = 0.5) ng/ml per h. In a separate group of 5 rabbits, angiotensin II was infused at 10, 25 and 50 ng/kg per min i.v. or methoxamine was infused at 10 and 25 micrograms/kg per min i.v. After indomethacin pretreatment, angiotensin II caused a significantly greater rise in mean arterial pressure and greater fall in renal vascular conductance, but there was no effect on the GFR response. In contrast, methoxamine caused significantly smaller falls in GFR, renal blood flow and renal vascular conductance after indomethacin pretreatment. Indomethacin significantly lowered resting GFR but not renal blood flow or arterial pressure. Thus, indomethacin pretreatment accentuated the renal vasoconstriction to angiotensin II, reduced the renal vasoconstriction to methoxamine and had no effect on the responses to haemorrhage. The results therefore suggest that prostaglandins do not act to lessen the renal effects of all vasoconstrictor stimuli, but that the prostaglandin response depends on the nature of the ischaemic stimulus.

Mechanisms involved in the renal responses to intravenous and renal artery infusions of noradrenaline in conscious dogs

1. The renal haemodynamic and glomerular filtration rate (G.F.R.) responses to intravenous and intrarenal infusions of noradrenaline were studied in conscious dogs, either with or without prior blockade of angiotensin II formation with teprotide. 2. Infusion noradrenaline by either route resulted in dose-related rises in plasma renin activity. 3. Pretreatment with teprotide reduced the rise in mean arterial pressure and abolished the rise in G.F.R. seen during intravenous infusions of noradrenaline (0.1, 0.2 and 0.4 microgram/kg . min). Noradrenaline also reduced filtration fraction more after teprotide pretreatment. 4. Renal blood flow rose and renal vascular resistance fell in response to I.V. noradrenaline infusions. This renal vasodilatation was unaffected by pretreatment of the dogs with teprotide, indomethacin or DL-propranolol. However after pentolinium pretreatment, I.V. noradrenaline infusion caused a dose-related renal vasoconstriction. 5. Infusion of noradrenaline into the renal artery (0.02, 0.05 and 0.1 microgram/kg . min) resulted in rises in mean arterial pressure and G.F.R. which were abolished by teprotide pretreatment. Filtration fraction rose when noradrenaline was administered alone but fell when it was infused after teprotide treatment. 6. Thus angiotensin II formed as the result of increased renin release acted to maintain G.F.R. and filtration fraction during noradrenaline infusion. In addition, I.V. noradrenaline infusions in conscious dogs caused reflex vasodilatation of the renal vasculature.

Role of the autonomic nervous system in the acute responses to renal artery pressure reduction in conscious dogs

1. Plasma renin and arterial pressure responses to acute renal artery pressure reduction were compared in intact dogs and "autonomically-blocked" dogs subjected to adrenalectomy, chronic guanethidine treatment and acute vagal block (methscopolamine). 2. Following reduction of renal artery pressure plasma renin activity and concentration rose more in the autonomically blocked dogs than in the intact dogs. When renal artery pressure was held at 30 mmHg for 1 h, plasma renin activity rose by 19.1 ng/ml per h (range 11.6-28.7) in autonomically blocked dogs and 3.65 ng/ml per h (range 1.54-5.89) in intact dogs. When renal artery pressure was held at 60 mmHg plasma renin activity rose 3.28 ng/ml per h (range 2.4-4.7) and 1.90 ng/ml per h (range 1.30-3.56), respectively. 3. Arterial blood pressure also rose more in autonomically blocked dogs in accord with the greater rise in plasma renin activity. The relationships between the increases in arterial pressure and plasma renin were closely similar in the two groups. 4. We conclude that the release of renin and increase in arterial blood pressure in response to renal artery stenosis is normally inhibited by arterial baroreflexes.

Cardiac norepinephrine output during carotid body stimulation

In a series of 7 dogs, selective stimulation of the carotid body receptors by hypoxic blood produces an increase of coronary flow and greater release of norepinephrine from the heart; the increase of coronary flow is less marked and the release of norepinephrine is increased after vagotomy. Myocardial norepinephrine content is decreased by carotid body stimulation.

Effects of hemorrhage on regional blood flow distribution in dogs and primates

The effects of hemorrhage on arterial pressure, blood flows, and resistances in the coronary, mesenteric, renal, and iliac beds of healthy, conscious dogs and intact, tranquilized baboons were studied. Mild nonhypotensive hemorrhage (14+/-2 ml/kg) increased heart rate and mesenteric and iliac resistances slightly but significantly, and decreased renal resistance (-13+/-2%). Moderate hypotensive hemorrhage, 26+/-2 ml/kg, reduced mean arterial pressure (-23+/-2 mm Hg) and blood flows to the mesenteric (-56+/-3%), iliac (-58+/-5%), and coronary (-39+/-4%) vascular beds, and increased heart rate (+89+/-9 beats/min) and resistances in the mesenteric (+73+/-15%), iliac (+102+/-19%), and coronary (+27+/-5%) beds. In contrast to the other beds, renal flow rose 11+/-6% above control and renal resistance fell 31+/-2% below control. Renal vasodilatation with hemorrhage was also observed in five baboons. The increases in mesenteric and iliac resistances were blocked almost completely by phentolamine, while the increase in coronary resistance was only partially blocked by phentolamine. The renal dilatation was not blocked by phentolamine, propranolol, atropine, or tripelennamine, but was prevented by indomethacin, suggesting that this dilatation was mediated by a prostaglandin-like compound. Thus the peripheral vascular responses to hemorrhage involve intense vasoconstriction in the mesenteric and iliac beds. In the normal conscious dog and the intact, tranquilized primate, the renal bed does not share in the augmentation of total peripheral resistance with nonhypotensive and moderate hypotensive hemorrhage, but does with more severe hemorrhage. In fact, renal vasodilatation occurs with nonhypotensive or moderate hypotensive hemorrhage, which can be prevented by blockade of prostaglandin synthetase with indomethacin.

Redistribution of Renal Blood Flow in Haemorrhagic Hypotension Role of Renal Nerves and Circulating Catecholamines* *

Haemorrhagic hypotension (HH) causes a redistribution of intrarenal blood flow characterized by a patchy cortical hypoperfusion. Previous studies indicated that the sYmpathoadrenergic system is mainly responsible for these redistribution processes. The relative role of renal nerves and of circulating catecholamines was studied in the present experiments. Intrarenal haemodynamics were analysed by means of the ¹³³ Xenon washout technique and ⁸³ Krypton autoradiographics. 8 autotransplanted (and, therefore, chronically denervated) kidneys showed the same typical response to severe and prolonged HH as 11 normal control organs. In 2 additional dogs, the intrarenal distribution of blood flow (IDBF) and local blood flow rates (F_i ) of an acutely denervated kidney before and during HH did not show any differences as compared with the contralateral control organ. It is concluded that the patchy cortical hypoperfusion observed in the dog during severe haemorrhagic hypotension does not depend on an intact innervation of the kidney, but that it is mainly mediated by circulating catecholamines.