Micropuncture study of hypertonic mannitol diuresis in the proximal and distal tubule of the dog kidney

Effect of a single dose of mannitol on hydration status and electrolyte concentrations in patients with tick-borne encephalitis

OBJECTIVE

This study was performed to assess the effect of a single dose of 15% mannitol on the hydration status and electrolyte balance in patients with tick-borne encephalitis (TBE).

METHODS

Forty-one patients with TBE were treated with 0.25 g/kg of 15% mannitol. The electrolyte concentrations (Na, K, and Cl), creatinine concentration, and hydration status were measured before and after mannitol infusion.

RESULTS

After mannitol administration, 7 patients had hyponatremia, 3 had hypokalemia, 1 had hyperkalemia, and 17 had hypochloremia. The total body water volume (TBW) changed by 0.44% ± 0.55%, the external body water volume (EBW) changed by 0.12% ± 0.15%, and the internal body water volume (IBW) changed by 0.19% ± 0.40%. The mean ECW/ICW ratio was 0.7694 ± 0.07 before treatment and 0.7699 ± 0.07 after treatment. Age was correlated with the TBW change in men (R = 0.42, p < 0.05) and with the potassium change in women (R = 0.66, p < 0.05).

CONCLUSIONS

Patients with TBE should receive mannitol two to four times daily depending on the clinical manifestation. Administration of a single dose of mannitol (0.25 g/kg) requires at least 300 mL of fluid supplementation. Bioimpedance might be useful for individual evaluation of dehydration. Additionally, patients require monitoring for potential hyponatremia. Older men may be more prone to dehydration after receiving mannitol.

The kidney in congestive heart failure: 'are natriuresis, sodium, and diuretics really the good, the bad and the ugly?'

This review discusses renal sodium handling in heart failure. Increased sodium avidity and tendency to extracellular volume overload, i.e. congestion, are hallmark features of the heart failure syndrome. Particularly in the case of concomitant renal dysfunction, the kidneys often fail to elicit potent natriuresis. Yet, assessment of renal function is generally performed by measuring serum creatinine, which has inherent limitations as a biomarker for the glomerular filtration rate (GFR). Moreover, glomerular filtration only represents part of the nephron's function. Alterations in the fractional reabsorptive rate of sodium are at least equally important in emerging therapy-refractory congestion. Indeed, renal blood flow decreases before the GFR is affected in congestive heart failure. The resulting increased filtration fraction changes Starling forces in peritubular capillaries, which drive sodium reabsorption in the proximal tubules. Congestion further stimulates this process by augmenting renal lymph flow. Consequently, fractional sodium reabsorption in the proximal tubules is significantly increased, limiting sodium delivery to the distal nephron. Orthosympathetic activation probably plays a pivotal role in those deranged intrarenal haemodynamics, which ultimately enhance diuretic resistance, stimulate neurohumoral activation with aldosterone breakthrough, and compromise the counter-regulatory function of natriuretic peptides. Recent evidence even suggests that intrinsic renal derangements might impair natriuresis early on, before clinical congestion or neurohumoral activation are evident. This represents a paradigm shift in heart failure pathophysiology, as it suggests that renal dysfunction-although not by conventional GFR measurements-is driving disease progression. In this respect, a better understanding of renal sodium handling in congestive heart failure is crucial to achieve more tailored decongestive therapy, while preserving renal function.

Mannitol increases renal blood flow and maintains filtration fraction and oxygenation in postoperative acute kidney injury: a prospective interventional study

Introduction

Acute kidney injury (AKI), which is a major complication after cardiovascular surgery, is associated with significant morbidity and mortality. Diuretic agents are frequently used to improve urine output and to facilitate fluid management in these patients. Mannitol, an osmotic diuretic, is used in the perioperative setting in the belief that it exerts reno-protective properties. In a recent study on uncomplicated postcardiac-surgery patients with normal renal function, mannitol increased glomerular filtration rate (GFR), possibly by a deswelling effect on tubular cells. Furthermore, experimental studies have previously shown that renal ischemia causes an endothelial cell injury and dysfunction followed by endothelial cell edema. We studied the effects of mannitol on renal blood flow (RBF), glomerular filtration rate (GFR), renal oxygen consumption (RVO₂), and extraction (RO₂Ex) in early, ischemic AKI after cardiac surgery.

Methods

Eleven patients with AKI were studied during propofol sedation and mechanical ventilation 2 to 6 days after complicated cardiac surgery. All patients had severe heart failure treated with one (100%) or two (73%) inotropic agents and intraaortic balloon pump (36%). Systemic hemodynamics were measured with a pulmonary artery catheter. RBF and renal filtration fraction (FF) were measured by the renal vein thermo-dilution technique and by renal extraction of chromium-51-ethylenediaminetetraacetic acid (⁵¹Cr-EDTA), respectively. GFR was calculated as the product of FF and renal plasma flow RBF × (1-hematocrit). RVO₂ and RO₂Ex were calculated from arterial and renal vein blood samples according to standard formulae. After control measurements, a bolus dose of mannitol, 225 mg/kg, was given, followed by an infusion at a rate of 75 mg/kg/h for two 30-minute periods.

Results

Mannitol did not affect cardiac index or cardiac filling pressures. Mannitol increased urine flow by 61% (P < 0.001). This was accompanied by a 12% increase in RBF (P < 0.05) and a 13% decrease in renal vascular resistance (P < 0.05). Mannitol increased the RBF/cardiac output (CO) relation (P = 0.040). Mannitol caused no significant changes in RO₂Ext or renal FF.

Conclusions

Mannitol treatment of postoperative AKI induces a renal vasodilation and redistributes systemic blood flow to the kidneys. Mannitol does not affect filtration fraction or renal oxygenation, suggestive of balanced increases in perfusion/filtration and oxygen demand/supply.

Diuretics: a review

Diuretics, in one form or another, have been around for centuries and this review sets out to chart their development and clinical use. Starting with the physiology of the kidney, it progresses to explain how diuretics actually work, via symports on the inside of the renal tubules. The different classes of diuretics are characterized, along with their mode of action. The clinical use of diuretics in conditions like congestive cardiac failure and hypertension, as well as some rarer, but clinically important, conditions is then examined. An account is given of the adverse effects of diuretics and how they come about. Common adverse effects like hypokalaemia and hyponatraemia are examined in some detail, and other electrolyte disturbances like hypomagnesaemia also gain a mention. Diuretic use in chronic kidney disease is examined and new guidelines that have been introduced are presented. A section on diuretic abuse is included as this is becoming an all too common clinical scenario, and the sometimes tragic consequences of this abuse are emphasized. Diuretics also find a role in the diagnosis of forms of renal tubular acidosis and this role is explored. Finally, a selection of some of the newer approaches to diuretic therapy are presented, often the consequence of the increasing development of molecular biology, and some of the novel compounds – which may be in drug formularies of the future – are revealed.

Effects of mannitol alone and mannitol plus furosemide on renal oxygen consumption, blood flow and glomerular filtration after cardiac surgery

OBJECTIVE

Imbalance of the renal medullary oxygen supply/demand relationship can cause hypoxic medullary damage and ischaemic acute renal failure (ARF). The use of mannitol for prophylaxis/treatment of clinical ischaemic ARF is controversial and the effect of mannitol on renal oxygenation in man has not yet been investigated. We evaluated the effects of mannitol on renal oxygen consumption (RVO(2))(,) renal blood flow (RBF) and glomerular filtration rate (GFR) in postoperative patients.

DESIGN

Prospective interventional study.

SETTING

University hospital cardiothoracic ICU.

PATIENTS

Ten uncomplicated mechanically ventilated and sedated postcardiac surgery patients with preoperatively normal renal function.

INTERVENTIONS

Mannitol infusion (225 mg/kg + 75 mg/kg/h) and combined mannitol and furosemide infusion (0.25 mg/kg + 0.25 mg/kg/h).

MEASUREMENTS AND RESULTS

Systemic haemodynamics were evaluated by a pulmonary artery catheter. RBF and GFR were measured by the renal vein thermodilution technique and by renal extraction of (51)Cr-EDTA, respectively. Mannitol increased urine flow (60%), GFR (20%) and filtration fraction (FF) (20%) with no change in RBF. This was accompanied by an increase in renal sodium reabsorption (18%), RVO(2) (19%) and renal oxygen extraction (21%). When combined with mannitol, furosemide normalised sodium reabsorption, RVO(2), renal oxygen extraction with no change in RBF, while GFR and FF were still elevated compared to control.

CONCLUSIONS

In patients with normal renal function, mannitol increases GFR, which increases tubular sodium load, sodium reabsorption and RVO(2) after cardiac surgery. The lack of effect on RBF, indicates that mannitol impairs the renal oxygen supply/demand relationship. Furosemide normalised renal oxygenation when combined with mannitol.

Prophylaxis of Iodinated Contrast Media-Induced Nephropathy

Iodinated contrast media are a frequent cause of acute renal failure, especially in patients whose renal function is already impaired. In addition to hydration, which remains the most commonly acknowledged means of protection, numerous pharmacological approaches for the prophylaxis of contrast nephropathy have been tested so far. They include diuretics, calcium channel blockers, adenosine receptor antagonists, N-acetylcysteine, low-dose dopamine and the dopamine D1 receptor agonist fenoldopam, endothelin receptor antagonists, and even captopril. The present review of the literature critically discusses the drugs used to prevent contrast nephropathy from a pharmacological point of view.

Renal blood flow, early distal sodium, and plasma renin concentrations during osmotic diuresis

Inconsistencies in previous reports regarding changes in early distal NaCl concentration (ED(NaCl)) and renin secretion during osmotic diuresis motivated our reinvestigation. After intravenous infusion of 10% mannitol, ED(NaCl) fell from 42.6 to 34.2 mM. Proximal tubular pressure increased by 12.6 mmHg. Urine flow increased 10-fold, and sodium excretion increased by 177%. Plasma renin concentration (PRC) increased by 58%. Renal blood flow and glomerular filtration rate decreased, however end-proximal flow remained unchanged. After a similar volume of hypotonic glucose (152 mM), ED(NaCl) increased by 3.6 mM, (P < 0.01) without changes in renal hemodynamics, urine flow, sodium excretion rate, or PRC. Infusion of 300 micromol NaCl in a smaller volume caused ED(NaCl) to increase by 6.4 mM without significant changes in PRC. Urine flow and sodium excretion increased significantly. There was a significant inverse relationship between superficial nephron ED(NaCl) and PRC. We conclude that ED(Na) decreases during osmotic diuresis, suggesting that the increase in PRC was mediated by the macula densa. The results suggest that the natriuresis during osmotic diuresis is a result of impaired sodium reabsorption in distal tubules and collecting ducts.

Treatment of acute hyponatremia: ensuring the excretion of a predictable amount of electrolyte-free water

BACKGROUND

Hypertonic saline is the recommended therapy to shrink swollen brain cells in patients with acute hyponatremia accompanied by seizures.

OBJECTIVES

In the absence of hypertonic saline, hypertonic mannitol will shrink the cell volume. Because mannitol is excreted rapidly, our aim was to ensure that it would be excreted with electrolyte-free water (EFW) and to evaluate the renal mechanisms responsible for EFW excretion.

DESIGN

A randomized, prospective, placebo-controlled study in rats was carried out in a research laboratory.

SUBJECTS

Adult male Wistar rats.

INTERVENTIONS

The control group of rats (n = 6) was administered hypotonic saline, a loop diuretic, vasopressin, and glucose by the intraperitoneal route; in the experimental group (n = 6), glucose was replaced with mannitol. Plasma electrolytes were measured at 0 and 210 mins, and balances for water, sodium, and potassium were obtained from 0 to 90 mins and from 90 to 210 mins.

MEASUREMENTS AND MAIN RESULTS

Virtually 100% of the administered mannitol was excreted within 210 mins, and half was excreted in the first 90 mins. The urine contained EFW only in the mannitol group because of a larger volume in the first 90 mins (EFW, 3.7 mL) and to a lower excretion of NaCl in the next 120 mins (EFW, 3.5 mL).

CONCLUSIONS

The combined use of mannitol and a loop diuretic caused the excretion of a predictable volume of EFW because the urine was iso-osmotic to plasma and contained all the administered mannitol. The calculated decrease in intracellular fluid volume was equivalent when mannitol was retained or excreted.

A decrease in renal medullary tonicity stimulates anion transport in Henle's loop of rat kidneys

To investigate the effect of reduction in renal medulla osmolality on loop of Henle (LOH) net bicarbonate reabsorption, clearance and microperfusion experiments were performed on Sprague-Dawley rats. The decrease of renal medulla osmolality was induced by intravenous infusion of either a large dose of mannitol (mannitol protocol) or a hypotonic solution (hypotonic protocol) delivered at a rate to match the sodium and bicarbonate load of the control period. During the mannitol protocol, clearance data demonstrated a rise in glomerular filtration rate (GFR), renal plasma flow, urine pH, and fractional bicarbonate excretion. On the contrary, microperfusion experiments, performed in the absence of mannitol in the tubular perfusate, revealed a significant increase both in the absolute and fractional LOH bicarbonate transport. During the hypotonic protocol, there was a decrease in GFR, associated with an increase in fractional excretion of bicarbonate. In the microperfusion experiments, hypotonic saline, similar to mannitol, stimulated absolute and fractional LOH bicarbonate transport. Net reabsorption of chloride, measured under the same experimental conditions, was also found to be activated. Therefore, the intravenous infusion of hypotonic solution affected the LOH transepithelial net reabsorption of both bicarbonate and chloride. We hypothesize that the increase in the transport rate of these two anions, along the same segment and in similar experimental conditions, may be mediated, at least in part, by decreased medullary tonicity, which is one factor common both to hypertonic mannitol and hypotonic saline infusion.

Factors contributing to the degree of polyuria in a patient with poorly controlled diabetes mellitus

Polyuria due to a glucose-induced osmotic diuresis is common in patients with hyperglycemia. This diuresis usually abates when the plasma glucose level approaches its renal threshold; the usual time course is less than 8 hours after commencing therapy. A 69-year-old man with non-insulin-dependent diabetes mellitus maintained hyperglycemia (540 mg/dL) and polyuria (4.7 L/24 hr) for 40 hours. Because there was no external supply of glucose, a balance study was conducted between the third and 40th hour after commencing treatment. In this interval, the overall concentration of glucose in the urine was less than 100 mmol/L and the urine osmolality was 378 mOsm/kg H2O. To evaluate the expected composition of the urine during a glucose-induced osmotic diuresis, urine was analyzed in normal rats infused with glucose plus urea and in untreated BB diabetic rats (plasma glucose and urea similar to that in our patient) as well as in 29 patients with hyperglycemia and polyuria. Glucose accounted for 60% of the urinary osmoles in rats and humans. Two subgroups of patients had a much lower urine glucose: one had an impaired concentrating ability (n = 6) and the other had an increased rate of renal glucose reabsorption (n = 5). In conclusion, in polyuria caused by hyperglycemia, the urine glucose should be 300 to 400 mmol/L with normal renal function. In the case we report, both the concentration of glucose and its excretion rate were much lower than expected with steady-state hyperglycemia (540 mg/dL) due to the high rate of excretion of NaCl, a concentrating defect, and excessive renal reabsorption of glucose.

Effects of hyperosmotic mannitol infusion on hemodynamics of dog kidney

This study evaluated the effect of systemic infusion of hypertonic mannitol on renal hemodynamics (aortic pressure [P]-renal blood flow [RBF] relationship, glomerular filtration rate [GFR], and effective renal plasma flow [ERPF]) during 50% reduction of left kidney blood flow. Conditioned mongrel dogs anesthetized with halothane were hydrated by continuous infusion of lactated Ringer's solution containing creatinine to measure GFR and p-aminohippurate (PAH), to measure ERPF. The left kidney was exposed and two hydraulic occluders were placed, one around the aorta just above the renal arteries and the other around the left renal artery. Experimental design consisted of measuring P near the left renal artery, RBF by electromagnetic flowmeter, and ERPF and GFR by clearance methods in both kidneys in response to stepwise reduction in the aortic pressure by aortic occlusion before and after 50% reduction in the left kidney blood flow. The P-RBF relationship, GFR, and ERPF thus obtained were compared with those obtained during systemic intravenous infusion of 20% mannitol for a period of 1 h. We found that 1) a transient increase occurred in RBF with step reduction of P from 80 to 60 mm Hg under control conditions; 2) reducing the RBF by 50% changed the shape of the P-RBF relationship from a convex to the P axis to a linear form with a marked shift toward the P axis; 3) infusion of mannitol, during reduced RBF, caused a significant shift of the P-RBF curve toward the RBF axis and returned the linear P-RBF relationship toward normal, but had no effect on altered yield pressure; and 4) infusion of hypertonic mannitol had slightly increased GFR and ERPF in the right (unconstricted) kidney. However, hypertonic mannitol significantly increased GFR and ERPF values in the left (constricted) kidney suggesting a beneficial effect of mannitol on ischemic kidney. The results are consistent with the hypothesis that infusion of hypertonic mannitol to ischemic kidney increases RBF, presumably by decreasing the intrarenal vascular resistance. We speculate that this compensatory response may be mediated either 1) by stimulating the release of a vasodilator substance (e.g., prostaglandins), or 2) by washing out interstitial sodium, thereby reducing the sensitivity of the renal vasculature to ischemia-induced stimulation of renin-angiotensin system.

Reabsorption of nitro-L-arginine infused into the late proximal tubule participates in modulation of TGF responsiveness

Previous studies indicate that endothelium-derived nitric oxide (NO) can directly modulate afferent arteriolar tone and that macula densa-derived NO can indirectly regulate afferent arteriolar tone by modulating the tubuloglomerular feedback (TGF) mechanism. The present in vivo micropuncture study evaluated whether the effect of late proximal tubular perfusion with the nitric oxide synthase (NOS) inhibitor, NG-L-arginine (NLA), on TGF responsiveness is related to reabsorption of NLA. Late proximal perfusion of 10(-3) M NLA resulted in a gradual, time-dependent enhancement of maximum TGF-mediated decreases in stop-flow pressure (SFP) from -7.1 +/- 0.7 to -19.4 +/- 1.6 mm Hg (P < 0.01). A detailed recording of SFP revealed that the maximum response during late proximal perfusion of NLA was obtained eight to nine minutes following the initiation of the perfusion, whereas maximum TGF responses evoked by late proximal perfusion with ATF were reached within one to two minutes. NLA infused into the late proximal segment of a neighboring nephron also resulted in enhancement of maximum SFP feedback responses from -5.5 +/- 0.5 to -10.4 +/- 1.9 mm Hg (P < 0.05), indicating that NLA can be reabsorbed and can consequently influence TGF responses. Finally, maximum SFP feedback responses were obtained prior to and following late proximal perfusion of 10(-3) M NLA dissolved in ATF, 10(-3) M NLA dissolved in 285 mM mannitol, and following perfusion with mannitol without NLA.(ABSTRACT TRUNCATED AT 250 WORDS)

Osmoregulation of vasopressin and thirst: comparison of 20% mannitol with 5% saline as osmotic stimulants in healthy man

OBJECTIVE

Osmoregulation is normally studied using a 5% saline infusion. This may be deleterious in fluid overloaded patients. Twenty per cent mannitol is another osmotic stimulant. This study aimed to compare 20% mannitol infusion with 5% saline as an osmotic stimulant to thirst and vasopressin secretion in normal volunteers.

DESIGN AND PATIENTS

Eight healthy volunteers studied on 2 occasions in random order. Each study involved a 2-hour infusion period of either hypertonic (5%) saline (0.06 ml/kg/h) or hypertonic (20%) mannitol (0.07 ml/kg/h).

MEASUREMENTS

Plasma vasopressin (pVp), plasma sodium, plasma osmolality (pOsm), haematocrit (HCT), blood pressure, thirst, blood glucose and volume drunk at end of infusion.

RESULTS

Five per cent saline infusion stimulated significantly higher levels of pOsm, pVp and thirst than 20% mannitol. Plasma sodium rose significantly during 5% saline infusion and fell during 20% mannitol infusion. HCT fell and mean arterial pressure rose in both infusions but the changes were not clinically significant. Piecewise linear regression analysis defined the overall threshold for pVp release for the two solutions as 5% saline, 292 mosm/kg and 20% mannitol, 291 mosm/kg, and the post threshold slope as 5% saline, 0.46 pmol/l pVp per mosm and 20% mannitol, 0.30 pmol/l pVp per mosm. The threshold for thirst onset was 5% saline, 291 mosm/kg and 20% mannitol, 290 mosm/kg, and the post threshold slope, 5% saline, 0.58 cm thirst per mosm and 20% mannitol, 0.28 cm thirst per mosm. The differences between the calculated osmotic thresholds and slopes post threshold for the two infusions were not significant for the pVp versus pOsm relationship. The difference between the cumulative volume drunk following the two infusions did not reach statistical significance. Mannitol caused a significant diuresis.

CONCLUSIONS

Twenty per cent mannitol infusion is an effective osmotic stimulant to thirst and vasopressin release in normal individuals, but is less potent than 5% saline infusion.

Effects of chronic, urea-induced osmotic diuresis on kidney weight and function in rats

To study the effects of chronic osmotic diuresis which were not associated with hyperglycaemia on the rat kidney, osmotic diuresis was induced by i.v. infusion of urea. A 5 mol/l urea solution was continuously infused at a rate of 100 ml.kg-1 x day-1 on the basis of body weight on day 0. Duration of infusion was 2, 6, 10 or 14 days. Control rats received continuously infused Ringer's solution. Urea-treated groups developed osmotic diuresis (urine flow = about 0.04 ml.min-1 x 100 g body weight-1) comparable to that in rats with experimental diabetes mellitus induced by i.v. streptozotocin (55 mg/kg), however urea-induced osmotic diuresis was not associated with blood glucose level increases. Compared with their controls, rats receiving urea for 2-14 days had markedly increased kidney weight. Rats receiving urea for 10 days showed greatest kidney weight increase, 0.565 +/- 0.044 g/100 g body weight (mean +/- SD), representing a 53% increase compared with the control (0.369 +/- 0.034 g/100 g body weight). Kidney weight was associated with increases in kidney protein content. In contrast, none of control kidney weight values differed significantly from day 0 values (= normal rats; 0.387 +/- 0.028 g/100 g body weight). Creatinine clearance values in urea-treated groups were also higher than those in controls. The maximum value, 0.65 +/- 0.17.ml-min-1 x 100 g body weight-1, was recorded in the 14-day group and was significantly higher than the corresponding control value (0.34 +/- 0.07 ml.min-1 x 100 g body weight-1) (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Where the kidney is concerned, how much mannitol is too much?

OBJECTIVE

To report a case of mannitol-induced acute renal failure (ARF).

CASE SUMMARY

A 31-year-old woman who had been on long-term warfarin therapy for atrial fibrillation was admitted to the hospital with hemoptysis. Following reversal of her anticoagulation, she had a tonic-clonic seizure nine days after admission. An emergency computed tomography scan revealed cerebral edema, which was initially treated with hyperventilation and steroids. Two days later, a repeat scan showed progression of the cerebral edema with midline shift. Mannitol 550 g was infused over the next 28 hours, precipitating ARF. Despite prompt hemodialysis to reverse the renal failure, the patient died. This case of apparent mannitol-induced ARF illustrates several pathophysiologic effects of this agent.

DISCUSSION

Case reports in the literature discussing mannitol-induced ARF are reviewed and compared. A relationship between dose and ARF and its reversal with hemodialysis is postulated.

CONCLUSIONS

It is likely that sufficient doses of mannitol may lead to ARF. Limitation of dose may prevent and treatment with hemodialysis may reverse ARF in these instances.

The increased proximal tubular reabsorption of sodium and water is maintained in long-term insulin-dependent diabetics with early nephropathy

Proximal tubular reabsorption of sodium and water was investigated in long-term insulin-dependent diabetic patients with normoalbuminuria (group I, n = 19), microalbuminuria (group II, n = 39), diabetic nephropathy (group III, n = 12) and in 13 healthy age-matched subjects. Glomerular filtration rate was measured with the single injection, 51Cr-EDTA technique. The fluid flow rate out of the proximal tubules was assessed by the renal lithium clearance. Although glomerular filtration rate was significantly elevated in the diabetic patients (Group I: 122 +/- 16, Group II: 121 +/- 18, Group III: 110 +/- 17, CONTROLS: 105 +/- 13 ml/min X 1.73 m2), lithium clearance was similar in the four groups (Group I: 19 +/- 6, Group II: 22 +/- 7, Group III: 19 +/- 5, CONTROLS: 23 +/- 4 ml/min X 1.73 m2). Both absolute and fractional proximal reabsorption of sodium and water was enhanced in diabetes. Indices of distal tubular function did not differ between controls and patients with insulin-dependent diabetes. Sodium clearance was about the same in the four groups. Our study suggests that the enhanced proximal reabsorption of sodium and water in insulin-dependent diabetic patients is still observed despite the presence of incipient or overt diabetic nephropathy.

An examination of the site and mechanism of action of torasemide in man

Acute clearance studies were performed in normal subjects to determine the site and mechanism of action of torasemide (isopropyl-1-methyl-3 phenylamino-4 pyridil-3 sulphonyl-3-urea), a new diuretic agent, in the human kidney. The drug caused no change in glomerular filtration rate or effective renal plasma flow. Sodium excretion rose to 16% of filtered load, whereas there was a chloriuresis of 23%. During maximal water diuresis, the drug caused an increase in urine flow rate and a decrease in solute-free water clearance. Administration of the drug during hypertonic saline infusion into hydropenic subjects resulted in a marked decrease in water reabsorption from the collecting duct. Torasemide caused no change in phosphate excretion or in the percentage of filtered bicarbonate excreted, nor was urinary pH or net hydrogen ion excretion affected by the drug. The data suggest that the primary site of action of torasemide is the medullary portion of the ascending limb of the loop of Henle.

Mechanism of osmotic diuresis studied by infusion of NaHCO3 and mannitol in dogs

To examine whether mannitol and NaHCO3 are equally potent inhibitors of proximal tubular fluid reabsorption, experiments were performed in 10 anaesthetized volume-expanded dogs during continuous infusion of ethacrynic acid. At plasma pH 7.5, a rise in plasma osmolality of 40 mosmol kg-1 reduced the remaining tubular fluid reabsorption in five dogs by 14 +/- 3% during NaHCO3 infusion and by 28 +/- 1% during mannitol infusion. Bicarbonate reabsorption increased by 25 +/- 5% during NaHCO3 infusion and decreased by 14 +/- 1% during mannitol infusion. At equal rates of bicarbonate reabsorption the inhibitory effects on tubular fluid and NaCl reabsorption were slightly less during mannitol than during NaHCO3 infusion. In five other dogs studied at constant plasma concentration of sodium, changes in bicarbonate reabsorption were avoided by raising plasma pH to 7.7 during NaHCO3 infusion and by reducing plasma pH to 7.4 during mannitol infusion. Tubular fluid reabsorption was reduced 32 +/- 4% by NaHCO3 and 34 +/- 4% by mannitol infusion, indicating equal inhibitory effects. The mechanism may be that the osmotic force for paracellular reabsorption of water and NaCl across the tight junction is equally reduced by equiosmolal increments in the NaHCO3 and mannitol concentration of the proximal tubular fluid.

Effect of diabetes on natriuresis in the presence of ouabain and ethacrynic acid in perfused rat kidney

1. The effect of diabetes on renal sodium retention was investigated. 2. The technique involved retrograde perfusion from the renal veins via the kidneys, and then through the renal arteries and dorsal aorta. 3. Sodium retention by diabetic rat kidney was 58% lower than that in the normal rats. 4. Ouabain (15 mM) in perfusate increased sodium retention by 30% in normal rat kidney as compared to a 54% increase in diabetic rat kidney. 5. Ethacrynic acid (1 mM) in perfusate resulted in a 42% reduction in sodium retention in the normal rat kidney as compared to a 43% decrease in the diabetic rat kidney. 6. Control of hyperglycemia in diabetic rats with insulin therapy resulted in sodium retention that is not significantly different from that of normal rats. 7. The results suggest that diabetes has no effect on the peritubular ouabain-sensitive Na--K-ATPase pump, or the luminal ethacrynic acid-sensitive Na-K counter transport pump. Furthermore, the data suggest a reversible effect of diabetes on sodium retention during insulin therapy.

Drug therapy in the management of acute renal failure

Pharmacologic intervention aimed at altering the natural history of acute renal failure is a routine practice without scientific support of efficacy. Oliguria has become a separate disease entity with an apparent disregard for the underlying condition that caused it. Volume expansion is clearly beneficial in preventing many volume depleted patients from progressing to acute renal failure. While mannitol and furosemide have been used to "convert" oliguric acute renal failure to the more easy to manage non-oliguric acute renal failure, published reports suggest that responders were not as ill as non-responders. The use of dopamine to increase urine flow in patients with established acute renal failure is the current fashion, but there is little evidence that this drug raises the glomerular filtration rate or shortens the course of acute renal failure. These pharmacologic therapies increase the complexity and cost of care with little tangible evidence of benefit to the patient or the physician caring for the patient.

The effect of intravenous contrast medium on glomerular filtration rate

The changes in glomerular filtration rate (GFR) after intravenous contrast medium have been investigated with three contrast media of differing osmolality (monomer, dimer and non-ionic agent) in antidiuretic dogs with three different basal solute excretion rates. A transient increase in GFR after contrast medium was attributed to the wash-out of medullary creatinine at the onset of diuresis. The subsequent fall in GFR was greatest with the contrast media of higher osmolality and in those dogs without an underlying solute diuresis. With the monomer, the decrease in GFR produced a significant decrease in the amount of contrast medium excreted in the first few minutes after contrast injection. It is suggested that an important factor in the decrease in GFR is the rise in pressure in the renal tubules at the start of a diuresis, before they have had time to dilate. An underlying solute diuresis is considered to protect against the fall in GFR because tubular dilatation has already occurred in response to the basal solute load. The decrease in blood pressure during and after contrast medium injection did not correlate with the fall in GFR.

The role of the distal nephron mechanisms in the concentration of contrast medium in the urine

The concentrating mechanisms affecting contrast medium in the distal nephron have been studied using three contrast media of differing osmolality (monomer, dimer and non-ionic compounds) in antidiuretic dogs with three different basal solute excretion rates. Evidence has been obtained that, under conditions of contrast medium osmotic diuresis, the loop of Henle generates more free water. If the free water generated in response to the contrast medium solute load is reabsorbed in the collecting ducts, this can in part mask the different proximal tubular effects of contrast media of different osmolality. However, as basal solute excretion increases, the compensatory mechanism is overwhelmed and urine osmolality falls exponentially. At the higher basal solute excretion rates, different osmolar loads of contrast medium no longer produce different urine osmolalities and different urine contrast medium concentrations. It is therefore considered unlikely that contrast media of reduced osmolality will produce significant increases in urine contrast medium concentration under the conditions of solute diuresis which occur in renal failure.

Mechanism of osmotic diuresis

Mannitol might inhibit paracellular reabsorption of water and sodium chloride in the proximal tubules by reducing the osmotic driving force. We examined this hypothesis in anesthetized dogs. Bicarbonate reabsorption was kept constant by sodium bicarbonate infusion, and transcellular sodium chloride reabsorption was inhibited by ethacrynic acid. The glomerular filtration rate (GFR) was varied by altering renal perfusion pressure. Mannitol infusion reduced sodium chloride reabsorption from 62 +/- 5% to 33 +/- 5% of the filtered load. The calculated increase in reabsorbate osmolality, averaging 82 +/- 6 mOsm/kg H2O, was due to sodium bicarbonate and equalled the increase in plasma osmolality. Mannitol concentration averaged 81 +/- 7 mM in plasma and 101 +/- 12 mM in urine. A linear relationship between reabsorption and GFR (glomerulo-tubular balance) was maintained over the same range of GFR before and after mannitol infusion. Mannitol infusion reduced sodium chloride reabsorption from 2.6 to 1.4 moles for each mole of sodium bicarbonate reabsorbed. During mannitol infusion, acetazolamide inhibited sodium bicarbonate reabsorption as in control experiments, but reduced sodium chloride reabsorption less. We conclude that reduced water reabsorption increases sodium bicarbonate concentration in the paracellular fluid as much as mannitol concentration is raised in the plasma and glomerular filtrate. Along the proximal tubules, net osmotic force is progressively reduced as mannitol concentration rises, accounting for reduced water and sodium chloride reabsorption.

A micropuncture study of urate excretion by Cebus monkeys employing high performance liquid chromatography with amperometric detection of urate

Net renal reabsorption of endogenous urate was studied by the micropuncture technique in Cebus monkeys in the absence of osmotic diuresis. Most of filtered urate (more than 70%) was reabsorbed in the proximal convoluted tubules. Samples from early distal tubules contained 9% of filtered urate; approximately 18% being reabsorbed between the late proximal and early distal segments. There was no detectable reabsorption along the distal tubule. Fractional delivery of urate to late distal tubules was greater than fractional excretion, implying reabsorption of some 4% of filtered urate in the collecting system. However, we cannot exclude nephron heterogeneity as the cause of the difference. The foregoing results were obtained using the method of Pachla and Kissinger for the determination of urate. Urate is separated by high performance liquid chromatography and detected by an amperometric technique. We found the method to be sufficiently sensitive, precise and specific for renal micropuncture samples.

Mannitol

Mannitol may be useful clinically both as a diuretic and as an obligate extracellular solute. As a diuretic it can be used to treat patients with intractable edema states, to increase urine flow and flush out debris from the renal tubules in patients with acute tubular necrosis, and to increase toxin excretion in patients with barbiturate, salicylate or bromide intoxication. As an obligate extracellular solute it may be useful to ameliorate symptoms of the dialysis disequilibrium syndrome, to decrease cerebral edema following trauma or cerebrovascular accident, and to prevent cell swelling related to renal ischemia following cross-clamping of the aorta. Largely unexplored uses for mannitol include its use as an osmotic agent in place of dextrose in peritoneal dialysis solutions, its use to maintain urine output in patients newly begun on hemodialysis, and its use to limit infarct size following acute myocardial infarction.

Pathogenic mechanisms in early norepinephrine-induced acute renal failure: functional and histological correlates of protection

The present study investigated the protective effect of acute volume expansion (25%) with isotonic saline, isotonic mannitol, and hypertonic mannitol in a model of unilateral norepinephrine-induced acute renal failure (ARF). Three hours following a 40-min intrarenal infusion of norepinephrine (NE) (0.75 microgram/kg/min), inulin clearance had fallen from a control value of 54.1 +/- 6.5 to 1.3 +/- 1.3 ml/min in untreated dogs and fell similarly (P = NS) to 3.3 +/- 1.5 ml/min in animals preexpanded with 0.9% saline (0.75 ml/kg/min). In contrast, as compared to the untreated animals, inulin clearance 3 hr post NE infusion was significantly greater in dogs preexpanded with 5% mannitol (9.2 +/- 2.5 ml/min, P less than 0.01), or 20% mannitol (16.6 +/- 3.9 ml/min, P less than 0.01). The protective effects of 5% and 20% mannitol were not statistically different from each other. Recovery of renal excretory function in all groups, expressed as 3-hr post NE inulin clearance, correlated with the magnitude of pre NE solute excretion rate (r = 0.612, P less than 0.001) and osmolar clearance rate (r=0.593, P less than 0.001), but not with pre insult inulin clearance (r = 0.233, P = NS) or renal blood flow (r = 0.249, P = NS). In the presence of a profound fall in inulin clearance, proximal tubular (PT) pressures in untreated dogs 3 hr post NE infusion achieved a value equal to control (26 +/- 11 vs. 25 +/- 2 mm Hg). In contrast, pretreatment with isotonic mannitol produced a rise in PT pressure both before (45 +/- 4 mm Hg, P less than 0.05) and 3 hr post NE infusion (38 +/- 5 mm Hg, P less than 0.05). In all groups of animals, at both 3 and 24 hr post NE, tubular injury was observed but glomerular architecture remained normal by light and electron microscopy. Conclusion. the protective effect of mannitol in this reversible model of ARF did not correlate with inulin clearance, renal blood flow, extracellular fluid (ECF) volume, ECF hypertonicity, or renal histologic changes but did correlate with the solute excretion rate. The increased PT pressures with mannitol both before and after the NE insult could contribute to the protective effect of attenuating any relative intratubular obstruction.

Effect of amiloride on the renal response to saline expansion in new-born dogs

1. The renal effects of amiloride were studied in twenty-six new-born and nine adult dogs, with and without saline expansion. 2. Without saline expansion, amiloride inhibited more sodium reabsorption (normalized to GFR) in puppies than in adults (5.95 vs. 2.18 muequiv/ml. GFR, P less than 0.01). Amiloride inhibited sodium reabsorption more in saline expanded than in nonexpanded puppies (9.39 vs. 5.95 muequiv/ml. GFR, P less than 0.01) but there was no difference between expanded and non-expanded adults. 3. Saline expansion by itself increased fractional sodium excretion (CNa/GFR) more in the adult than in the puppy (0.071 vs. 0.019, P less than 0.01). During amiloride inhibition, saline expansion increased CNa/GFR to 0.045 in the puppy (compared to 0.019 in the nonamiloride inhibited puppy) but saline expansion increased CNa/GFR to the same degree in the amiloride as in the non-amiloride inhibited adult. 4. In all puppies amiloride inhibited more sodium reabsorption than potassium secretion and there was poor correlation between the degree of inhibition of sodium reabsorption and potassium secretion for both the puppy (r = 0.14) and the adult (r = 0.05). 5. Assuming that amiloride acts by inhibiting sodium reabsorption and potassium secretion in the late distal and cortical collecting tubules, these results support the conclusion that in these regions of the nephron of the new-born dog (a) a greater fraction of the filtered sodium is reabsorbed than in the adult and (b) increased fractional sodium reabsorption is responsible, in part, for the attenuated natriuretic response to saline expansion.

The effects of glucose and insulin on renal electrolyte transport

The effects of hyperglycemia and hyperinsulinemia on renal handling of sodium, calcium, and phosphate were studied in dogs employing the recollection micropuncture technique. Subthreshold sustained hyperglycemia resulted in an isonatric inhibition of proximal tubular sodium, fluid, calcium, and phosphate reabsorption by 8-14%. Fractional excretion of sodium and phosphate, however, fell (P is less than 0.01) indicating that the increased delivery of these ions was reabsorbed in portions of the nephron distal to the site of puncture and in addition net sodium and phosphate transport was enhanced resulting in a significant antinatriuresis and antiphosphaturia. The creation of a steady state plateau of hyperinsulinemia while maintaining the blood glucose concentration of euglycemic levels mimicked the effects of hyperglycemia on proximal tubular transport and fractional excretion of sodium and calcium. Tubular fluid to plasma insulin ratio fell, similar to the hyperglycemic studies. These results suggest that the effects of hyperglycemia on renal handling of sodium and calcium may be mediated through changes in plasma insulin concentration. In contrast to hyperglycemia, however, hyperinsulinemia cuased a significant fall in tubular fluid to plasma phosphate ratio with enhanced proximal tubular phosphate reabsorption (P is less than 0.02). This occurred concomitantly with a significant inhibition of proximal tubular sodium transport. These data indicate that insulin has a direct effect on proximal tubular phosphate reabsorption, and this effect of insulin is masked by the presence of increased amounts of unreabsorbed glucose in the tubule that ensues when hyperinsulinemia occurs secondary to hyperglycemia. Fractional excretion of phosphate fell significantly during insulin infusion but unlike the hyperglycemic studies, the fall in phosphate excretion could be entirely accounted for by enhanced proximal reabsorption.

Effect of mannitol on glomerular ultrafiltration in the hydropenic rat

The effect of mannitol upon glomerular ultrafiltration was examined in hydropenic Munich-Wistar rats. Superficial nephron filtration rate (sngfr) rose from 32.0+/-0.9 nl/min/g kidney wt to 42.0+/-1.6 (P < 0.001) in eight rats. Hydrostatic pressure gradients acting across the glomerular capillary (DeltaP) were measured in glomerular capillaries and Bowman's space with a servo-nulling device, systemic (piA) and efferent arteriolar oncotic pressures (piE) were determined by microprotein analysis. These data were applied to a computer-based mathematical model of glomerular ultrafiltration to determine the profile of effective filtration pressure (EFP = DeltaP - pi) and total glomerular permeability (L(p)A) in both states. Filtration equilibrium obtained in hydropenia (L(p)A >/= 0.099+/-0.006 nl/s/g kidney wt/mm Hg) and sngfr rose because EFP increased from a maximum value of 4.2+/-1.1 to 12.8+/-0.5 mm Hg after mannitol (P <0.01). This increase was due to both increased nephron plasma flow and decreased piA. Computer analysis of these data revealed that more than half (>58%) of this increase was due to decreased piA, consequent to dilution of protein. Since EFP was disequilibrated after mannitol, L(p)A could be calculated accurately (0.065 +/- 0.003 nl/s/g kidney wt/mm Hg) and was significantly lower than the minimum estimate in hydropenia.Therefore, sngfr does increase with mannitol and this increase is not wholly dependent upon an increase in nephron plasma flow since the major factor increasing EFP was decreased piA.

Micropuncture studies of phosphate transport in the proximal tubule of the dog. The relationship to sodium reabsorption

Micropuncture studies were performed in the dog to examine the relationship between sodium and phosphate transport in the proximal tubule. In hydropenic, thyroparathyroidectomized animals, administration of parathyroid extract, saline, or acetazolamide resulted in a fall in proximal tubule fluid-to-plasma (TF/P) inulin ratio as well as a rise in tubule fluid-to-plasma ultrafilterable (TF/UF) phosphate ratio. A correlation was found between the changes in fractional reabsorption of sodium and phosphate but the phosphate changes were generally greater than those of sodium. Also, a high distal phosphate delivery in the face of low fractional excretion of phosphate in the urine in thyroparathyroidectomized dogs suggests significant phosphate reabsorption in the distal nephron. On the other hand, calcium chloride infusion to saline-loaded, normal dogs to suppress endogenous parathyroid hormone reduced proximal TF/UF phosphate without change in TF/P inulin, while both parameters remained unchanged in saline-loaded, thyroparathyroidectomized dogs after calcium infusion. An increase in proximal TF/UF phosphate associated with unchanged TF/P inulin was also demonstrated by administration of highly purified parathyroid hormone to saline-loaded, thyroparathyroidectomized dogs. It was concluded that although proximal tubule phosphate transport is generally closely related to that of sodium, the two can dissociate under certain experimental conditions, especially under the influence of parathyroid hormone. These observations also indicate that the effect of parathyroid hormone on proximal tubule phosphate transport is not solely dependent upon its effect on sodium transport.

Micropuncture study of diuretic effects on sodium and calcium reabsorption in the dog nephron

A close relationship has been observed between the clearance rates of sodium and calcium under a variety of diuretic conditions. The thiazide diuretics act differently in dissociating the renal tubular reabsorption of sodium and calcium. This phenomenon has been further investigated using recollection micropuncture and clearance techniques in a group of 14 dogs subjected to three consecutive experimental phases: expansion to 3% of body weight (BWt) with Ringer's solution, chlorothiazide infusion at 20 mg/kg/h, and furosemide in a prime of 10 mg/kg/ and a 10 mg/kg/h infusion. Diuretic losses were balanced with infusion of equal volumes of Ringer's solution throughout the experiment. Chlorothiazide increased the fractional excretion (FE) of sodium almost threefold while FE(Ca) was not significantly altered. Furosemide increased FE(Na) and FE(Ca) to an approximately equal, and more marked, degree. This dissociation of sodium and calcium reabsorption after chlorothiazide was also evident in the superficial distal tubule, where (tubule fluid/plasma sodium) (TF/P(Na)) increased from 0.32 to 0.49 (P < 0.01) and TF/(ultrafiltrate)UF(Ca) was unchanged (0.35-0.31). Furosemide markedly reduced the transtubular concentration gradient for both sodium (0.86) and calcium (0.94). TF/P(Inul in) decreased progressively from 3.79 to 2.78 to 2.33 in three phases. In the late proximal tubule, chlorothiazide induced a fall of TF/P(Inul in) from 1.57 to 1.44 (P < 0.01), but the ratio TF/UF(Ca): TF/P(Na) was unchanged. Furosemide had no significant proximal effect. It is concluded that acute administration of chlorothiazide reduces sodium reabsorption in the distal hephron, presumably the cortical diluting segment, without affecting calcium reabsorption.

Effect of extracellular volume expansion upon sodium reabsorption in the distal nephron of dogs

Micropuncture studies have disclosed that extracellular fluid (ECF) volume expansion inhibits sodium reabsorption in the proximal tubule. The diuresis that ensues represents only a portion of the increment in sodium and water escaping proximal reabsorption, since a large and variable fraction of the increment is reabsorbed distally. In certain experimental models proximal reabsorption may be depressed by ECF volume expansion, yet only a negligible amount of sodium appears in the final urine. This suggests that saline diuresis is the consequence of depressed distal sodium reabsorption. Previous clearance and micropuncture studies have not conclusively proven this. Eight dogs were studied repeatedly: in some studies glomerular filtration rate and distal delivery were increased markedly without sodium administration; in others comparably high distal sodium loads were achieved by progressive 1/2 isotonic saline infusion. C(H2O) at high distal sodium loads was depressed by expansion of the ECF volume with hypotonic saline. The difference in free water formation between dogs which did and did not receive hypotonic saline was accounted for by the difference in sodium excretion. In one dog hypotonic saline expansion failed to depress free water formation; likewise the level of natriuresis in this dog was severely attenuated. The results of these experiments provide strong evidence that the natriuresis that occurs following ECF volume expansion with saline is a consequence of alteration in function of the distal nephron.

A definition of proximal and distal tubular compliance. Practical and theoretical implications

Micropuncture studies were carried out in the rat to evaluate the in situ distensibility characteristics of the proximal and distal tubules under a variety of experimental conditions. In the first phase, we determined the response of tubular diameter (D) to changes in tubular pressure (P) induced by partially obstructing single tubules. The response observed under these conditions (i.e., when interstitial pressure is presumed to be constant) has been defined as the compliance of the tubule. Over the range of tubular pressures studied (10-35 mm Hg for the proximal tubule, 5-25 mm Hg for the distal tubule) the compliance characteristics of the proximal and distal tubule were found to be markedly different; the proximal tubular pressure-diameter relationship was linear, DeltaD/DeltaP = 0.45 mum/mm Hg, whereas the distal pressure-diameter relationship was curvilinear, DeltaD/DeltaP = c(-0.1xP+2.2). In the second phase we used the compliance data to construct a series of theoretical pressure-diameter curves that define the response of the tubule to increments in interstitial as well as intratubular pressure. These curves indicate that changes in distal diameter should provide a sensitive index of a rise in interstitial pressure under conditions in which the transtubular pressure gradient is increased by a small amount, but that proximal diameter should provide a more sensitive index of changes in interstitial pressure when the transtubular pressure gradient is increased by a large amount. In subsequent experiments in which furosemide was administered, we observed that the pressure-diameter relationships for both the proximal and distal tubule were indistinguishable from the compliance curves, a finding consistent with the interpretation that interstitial pressure was not appreciably changed from control. By contrast, when mannitol was administered, both proximal and distal tubular pressure-diameter relationships were significantly altered in a fashion consistent with a large increase in interstitial pressure. Neither with furosemide nor mannitol administration did it appear likely that significant changes in tubular compliance could account for the observed behavior of the tubule.Finally, we propose that a knowledge of tubular compliance will be useful in exploring the interrelationships between tubular and peritubular pressures, tubular anatomy, and transtubular ionic permeability. Recent studies linking changes in the geometry of lateral intercellular spaces of the tubule to changes in passive ion movement suggest that an investigation of such anatomical-functional correlates should be productive.

Evidence for hemodynamic autoregulation of renin release

To examine the relationship between renal arteriolar dilatation and renin release, arterial perfusion pressure in anesthetized dogs was lowered in steps within and below the range of autoregulation of renal blood flow. Renin release, determined by both bioassay and radioimmunoassay, averaged 2.7 ± 0.9 ( SE ) µg/min at control pressure and increased to 20.0 ± 4.1 ( SE ) µg/min at the lowest autoregulating pressure, which averaged 66.4 ± 2.9 ( SD ) mm Hg. However, renin release then remained constant during further lowering of arterial perfusion pressure despite reductions in renal blood flow. This response was not significantly changed when sodium excretion was increased by intravenous infusion of mannitol. In another series of experiments, renin release was raised by reducing arterial perfusion pressure below the range of autoregulation, and control sodium excretion was reestablished by mannitol or saline infusion; renin release remained high. Therefore, renin release appears to be related to autoregulated dilatation of the renal arterioles, and it becomes maximal when the arterioles are completely dilated at the lowest pressure of autoregulation of renal blood flow. This mechanism is different from release mechanisms dependent on sodium delivery to the distal nephron.

Micropuncture studies of sodium transport in the remnant kidney of the dog. The effect of graded volume expansion

Proximal and distal tubule micropuncture studies were performed to examine the response to graded extracellular volume (ECV) expansion in 10 normal dogs (stage I), 11 dogs with a unilateral remnant kidney (stage II), and 7 dogs with a remnant kidney after removal of the contralateral kidney (stage III). Before ECV expansion in stage III, there was a suggestive reduction in proximal tubule as well as loop fractional reabsorption of sodium. After ECV expansion to 3% body weight proximal tubule reabsorption was depressed in all groups of animals, while little further inhibition was observed in this segment with additional expansion to 10% body weight. In contrast, the fraction of filtered sodium remaining in the distal tubule rose progressively in all three groups after graded ECV expansion, suggesting that the graded natriuretic response found in the final urine was largely due to a similar response in the loop of Henle rather than that in the proximal tubule. The distal tubule response of the remnant kidney in both stages II and III was greater than that in stage I. These data indicate that although enhanced sodium excretion per nephron in chronic renal failure may be related to uremia, its exaggerated response to ECV expansion is due, at least in part, to certain as yet unidentified intrarenal factors consequent to reduction in functioning renal mass.

Effects of acute volume expansion and altered hemodynamics on renal tubular function in chronic caval dogs

It is well established that dogs with chronic partial constriction of the thoracic inferior vena cava develop sodium retention, ascites, and respond poorly to acute saline loading. A group of such chronic caval dogs, and a group of normal controls were studied during hydropenia, and again after acute saline loading by clearance and recollection micropuncture techniques. After volume expansion, the caval dogs excreted 52 muEq/min per kidney of sodium compared with 370 muEq/min per kidney for the normal controls. During hydropenia and after the saline infusions, single nephron filtration rates, fractional reabsorption of sodium within the proximal tubule, and proximal delivery of filtrate to the distal nephron were comparable in both groups of dogs. Micropuncture of distal tubular segments confirmed that the loop of Henle was the major site for salt and water retention in the expanded caval dogs. Alteration of intrarenal hemodynamics by vasodilating one kidney and elevating systemic arterial blood pressure induced a normal natriuretic response in the saline-loaded caval dogs. Proximal tubular function remained unchanged and the loop of Henle appeared to be the major site responsive to these hemodynamic maneuvers. These same experiments in saline-loaded control dogs had no effect on function of the proximal or distal nephron and did not increase urinary excretion of sodium or water. These experiments provide evidence that the loop of Henle is the major site for sodium retention in volume-expanded chronic caval dogs excreting minimal amounts of sodium.

Hypernatremia. Complication of renal homotransplantation

Hypernatremia was observed in five reo cipients of renal homografts during the first postoperative week. The peak serum levels of sodium varied between 152 and 158 mEq Iliter. The postoperative diuresis was associated with sodium concentration in the urine, consistently lower than that in the extracellular water; moderate urinary hypertonicity, with urea being the main urinary solute; and urea excretion exceeding 60% of its filtered load in most instances. The inability of elaborate urine with sodium concentration equal or higher than that in the serum, possibly related to osmotic diuresis and/or altered renal hemodynamics, appears to be the primary cause responsible for the development of hypernatremia in these patients.