Urine concentration and dilution in hypokalemic and hypercalcemic dogs

Association of the Urine-to-Plasma Urea Ratio With CKD Progression

RATIONALE & OBJECTIVES

The urine-to-plasma (U/P) ratio of urea is correlated with urine-concentrating capacity and associated with progression of autosomal dominant polycystic kidney disease. As a proposed biomarker of tubular function, we hypothesized that the U/P urea ratio would also be associated with progression of more common forms of chronic kidney disease (CKD).

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

3,723 adults in the United States with estimated glomerular filtration rate (eGFR) of 20-70 mL/min/1.73 m², enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study.

EXPOSURE

U/P urea ratio, calculated from 24-hour urine collections and plasma samples at baseline.

OUTCOME

Associations of U/P urea ratio with eGFR slope, initiation of kidney replacement therapy (KRT), and CKD progression, defined as 50% decline in eGFR or incident KRT.

ANALYTICAL APPROACH

Multivariable linear mixed-effects models tested associations with eGFR slope. Cox proportional hazards models tested associations with dichotomous CKD outcomes.

RESULTS

The median U/P urea ratio was 14.8 (IQR, 9.5-22.2). Compared with participants in the highest U/P urea ratio quintile, those in the lowest quintile had a greater eGFR decline by 1.06 mL/min/1.73 m² per year (P < 0.001) over 7.0 (IQR, 3.0-11.0) years of follow-up observation. Each 1-SD lower natural log-transformed U/P urea ratio was independently associated with CKD progression (HR, 1.22 [95% CI, 1.12-1.33]) and incident KRT (HR, 1.22 [95% CI, 1.10-1.33]). Associations differed by baseline eGFR (P interaction = 0.009). Among those with an eGFR ≥30 mL/min/1.73 m², each 1-SD lower in ln(U/P urea ratio) was independently associated with CKD progression (HR, 1.30 [95% CI, 1.18-1.45]), but this was not significant among those with eGFR <30 mL/min/1.73 m² (HR, 1.00 [95% CI, 0.84-1.20]).

LIMITATIONS

Possibility of residual confounding. Single baseline 24-hour urine collection for U/P urea ratio.

CONCLUSIONS

In a large and diverse cohort of patients with common forms of CKD, U/P urea was independently associated with disease progression and incident kidney failure. Associations were not significant among those with advanced CKD at baseline.

[Secondary gout and pseudo-Bartter syndrome in females with laxative abuse]

Four females (27-54 y), presenting with a history of long-term laxative abuse, were admitted to the Medizinische Poliklinik for evaluation of generalized weakness. Laboratory findings revealed signs of Bartter's syndrome, including hypokalemia, systemic alkalosis and normal blood pressure. Three of the four females showed impaired renal function and elevated serum uric acid levels, two of them suffered from recurrent gouty attacks. In our patients the incidence of hyperuricemia and impaired renal function, as a consequence of chronic hypokalemia, was much higher than known from patients with Bartter's syndrome. Hyperuricemia is related to some pathophysiological features of Pseudo-Bartter's syndrome, (e.g. systemic alkalosis, elevated angiotensin) and combined with additional factors (e.g. catabolism, reduced plasma volume) may lead to gouty attacks. Gallstones were found in two of the four females. Long term surreptitious laxative ingestion frequently is observed in females. Hypokalemia, induced by the laxatives, causes reduced intestinal motility and leads to augmented laxative intake. These patients are prone to develop Pseudo-Bartter's syndrome, causing eventually a hyperuricemia and gouty attacks.

Ascites, renal abnormalities, and electrolyte and acid-base disorders associated with liver disease

Ascites and renal dysfunction are often associated with decreased liver function and reflect the complex abnormalities of water, protein, electrolyte, and acid-base metabolism that may complicate severe liver disease. This article discusses the pathophysiology and management of ascites, polydipsia and polyuria, decreased renal function, and acid-base and electrolyte alterations that can complicate liver disease.

The cyclic AMP system in the inner medullary collecting duct of the potassium-depleted rat

The present study was undertaken to investigate the cyclic AMP system in the isolated inner medullary collecting tubule (IMCT) of hypokalemic (HK) rats. In situ incubation of IMCT with 10(-7) M arginine vasopressin (AVP) at 300 mOsm/kg H2O in control normokalemic rats increased cyclic AMP content (fmoles/mm) from 5.68 +/- 1.41 to 30.3 +/- 5.31 (P less than 0.001). In HK rats the increase in cyclic AMP was blunted from 7.18 +/- 2.0 to 14.78 +/- 3.14 fmoles/mm (P less than 0.05 compared to controls). No such blunting was observed in the outer medullary collecting duct of hypokalemic rats, but was seen in the IMCT when studied at 800 (P less than 0.05), 1200 (P less than 0.01), and 2000 mOsm/kg H2O (P less than 0.05). The increase in cyclic AMP was also blunted in IMCT of HK rats not allowed to become polyuric or polydipsic by pair-watering studied at 300, 800, and 1200 mOsm/kg H2O. To define the process responsible for the failure to normally increase cyclic AMP in HK, adenylate cyclase activity (AC) was determined at 800 mOsm/kg H2O. While basal AC was not different, the response to all concentrations of AVP between 10(-10) and 10(-6) M was markedly depressed in tubules from HK rats. In contrast AC response to 10(-2) M NaF was not different in IMCT of normokalemic and HK rats. While the abnormal cyclic AMP content with AVP could be explained by abnormal generation, a contribution of increased metabolism was also sought.(ABSTRACT TRUNCATED AT 250 WORDS)

Time-dependent changes in inner medullary plasma flow rate during potassium-depletion

Renal concentrating ability becomes impaired after approximately 2 weeks of dietary potassium (K) depletion in the rat. Since inner medullary plasma flow (IMPF) has been shown to be reduced after 3 weeks of K-depletion, IMPF was measured after 2 and 3 weeks of dietary K-deprivation to determine if the change in IMPF is present at the time the renal concentrating defect first appears. In the present study, similar reductions in maximal urine concentration were present in rats K-depleted for 2 and 3 weeks. IMPF measured by the 125I albumin accumulation method, however, was normal after 2 weeks of K-depletion (control, 35.1 +/- 1.93 vs. K-depletion 2 weeks, 32.8 +/- 1.52 ml/min/100 g IM), and was reduced after 3 weeks of this dietary regime (K-depletion, 3 weeks: 13.8 +/- 1.84). To determine the mechanism of the decrease in IMPF after 3 weeks of K-depletion, rats were treated acutely with indomethacin. There was no significant change in IMPF in control or 3-week K-depleted rats following treatment with indomethacin. These results suggest that the reduction in medullary solute content after 2 weeks of K-depletion cannot be attributed to a reduction in IMPF. In addition, products of the cyclooxygenase enzyme systems do not appear to contribute in a major way to the reduction in IMPF measured after 3 weeks of dietary K-depletion.

Inhibition of transcellular NaCl reabsorption in dog kidneys during hypercalcemia

Reduced concentrating and diluting capacity of the kidney in acute and chronic hypercalcemia may partly be due to inhibition of transcellular sodium reabsorption (RNa) in the thick ascending limb of Henle's loop. To examine this hypothesis, local heat production and RNa were measured during normo- and hypercalcemia at comparable glomerular filtration rate (GFR) in volume expanded, anesthetized dogs. Changes in proximal RNa which might occur during CaCl2 infusion, were minimized by infusing acetazolamide (75 mg/kg body wt iv). When ultrafiltrable calcium was increased from 1.12 +/- 0.09 to 2.95 +/- 0.10 mmol/l, cortical heat production was unchanged, whereas outer medullary heat production fell by 32 +/- 4%. RNa was reduced by 32 +/- 6%. Bicarbonate reabsorption did not change but calcium reabsorption and potassium excretion increased significantly. The potassium content of cortex and outer medulla increased during hypercalcemia, whereas ouabain, an inhibitor of Na+, K+-ATPase reduces the potassium content. We conclude that hypercalcemia does not inhibit transcellular RNa in the diluting segment by a direct effect on the Na+, K+-ATPase or the mitochondria, but by interfering with the coupled NaCl transport across the luminal cell membrane.

Control of renal hemodynamics and glomerular filtration rate in chronic hypercalcemia. Role of prostaglandins, renin-angiotensin system, and calcium

The role of prostaglandins (PG), renin-angiotensin system (RAS) and calcium (Ca) in the control of renal hemodynamics and glomerular filtration rate (GFR) in chronic hypercalcemia (serum Ca 12.8 mg%) was studied. Renal blood flow (RBF, 6.39 ml/min per gram kidney weight [gkw]) and GFR (0.52 ml/min per gkw) were significantly decreased in hypercalcemic rats when compared with normocalcemic rats (7.15, P < 0.001 and 0.74, P < 0.05, respectively). These changes in RBF and GFR occurred independent of any significant alterations in systemic hemodynamics, blood and plasma volume. Inhibition of the renal PG with indomethacin resulted in marked decrements in both RBF (6.39-4.12 ml/min per gkw, P < 0.01) and GFR (0.52-0.19 ml/min per gkw, P < 0.01) in hypercalcemic rats, whereas there was no significant alterations in normocalcemic rats. Inhibition of the RAS with captopril resulted in marked increments in both RBF (6.39-7.35 ml/min per gkw, P < 0.05) and GFR (0.52-0.74 ml/min per gkw, P < 0.05) in hypercalcemic rats. In fact, there was no significant difference from the RBF and GFR of similarly treated normocalcemic rats. Similar results were also obtained with the competitive angiotensin II (AII) antagonist (sarcosyl(1)-isoleucyl(5)-glycyl(8)) AII. Since both the renal PG and the RAS are involved in the control of RBF and GFR in hypercalcemia, the role of each is best revealed in the absence of the other. Hence, comparison of the RBF and GFR in the PG-inhibited hypercalcemic rats in the presence of AII (4.12 and 0.19 ml/min per gkw, respectively) and absence of AII (5.99 and 0.53 ml/min per gkw, P < 0.01 for both) reveals the vasoconstrictive role for AII in hypercalcemia. On the other hand, comparison of the RBF and GFR in the AII-inhibited hypercalcemic rats in the presence of PG (7.35 and 0.74 ml/min per gkw, respectively) and absence of PG (5.99 and 0.53 ml/min per gkw, P < 0.01 and P < 0.05, respectively) reveals the vasodilatory role for PG in hypercalcemia. Finally, comparison of the RBF and GFR in both PG- and AII-inhibited hypercalcemic rats (5.99 and 0.53 ml/min per gkw, respectively) with similarly treated normocalcemic rats (7.30 and 0.94 ml/min per gkw, P < 0.001 and P < 0.005, respectively) reveals the vasoconstrictive role for Ca in chronic hypercalcemia. Our study therefore demonstrates that in chronic hypercalcemia the RBF and GFR are controlled by an active interplay of the vasoconstrictive effect of AII, the vasodilatory effect of renal PG, and the direct vasoconstrictive effect of Ca, independent of either AII or PG. The sum total of these forces produces a modest but significant decrease in RBF and GFR.

Plasma vasopressin in hypercalcaemic states

Plasma vasopressin was measured by radioimmunoassay in eight normal subjects and in six patients with hypercalcaemia. Vasopressin levels were significantly elevated in the hypercalcaemic patients, although urine osmolalities were lower than in controls. This finding is consistent with a renal resistance to the action of endogenous vasopressin in hypercalcaemia.

Disorders of urinary concentration and dilution

A new approach to the classification of disorders of urinary concentration and dilution is recommended based on recent studies of how the kidney elaborates a urine of widely varying osmolality. The capacity to concentrate urine depends on ft, the fractional reabsorption of solute delivered to the loop of Henle; fu, the excretion of solute relative to the sum of solute excretion and solute delivery to Henle's loop; fw, the fraction of solute loss by vascular outflow from the medulla relative to that reabsorbed by the loop; and finally, collecting duct response to antidiuretic hormone (ADH). A decrease in ft or in increased fu or fw will diminish urinary concentrating ability, as will resistance of the tubule to ADH. Conversely, urinary dilution depends on the delivery of sodium and water to the ascending limb; NaCl reabsorption by the ascending limb; and the absence of ADH. A decrease in sodium and water delivery to the ascending limb or in NaCl reabsorption by the ascending limb will impair urinary diluting ability, as will the presence of ADH. The consequences of disorders in urinary concentrating and diluting ability vary widely. In an alert patient with an intact thirst center, there may be no consequence; in a patient unable to communicate thirst or whose thirst center is deranged, the results may be catastrophic. Keeping in mind the kidney's few basic requirements for formation of concentrated or dilute urine may help the physician avoid these potentially serious dislocations of water balance.

Arachidonic acid metabolism, prostaglandins and the kidney

Renal prostaglandins are gaining increasing recognition as important modulators of hemodynamics and excretory function in the mammalian kidney. Synthesis of these unsaturated fatty acids from arachidonate precursors is closely regulated by intrarenal factors, and circulating angiotensin II, catecholamines, arginine vasopressin and bradykinin. Endogenous prostaglandins exert little influence on renal blood flow and glomerular filtration rate in the basal state, but inhibition of arachidonate metabolism when renal perfusion is impaired causes marked alterations in these parameters. Renal salt and water excretion is modified by the effects of prostaglandins on glomerular filtration rate, proximal tubule fluid reabsorption, medullary solute gradients, and the intrinsic water and ion reabsorptive properties of distal nephron segments. Prostaglandins also mediate renin release under basal conditions and in response to intravascular volume depletion. Abnormalities of renal prostaglandins are evident in various clinical disorders of renal function including hypertension, ureteral obstruction, Bartter syndrome, hypokalemic nephropathy and drug-induced disorders of water metabolism. Appropriate clinical use of nonsteroidal anti-inflammatory agents requires consideration of the potential renal consequences of inhibiting prostaglandin biosynthesis.

Renal function in hypercalcemic dogs during hydropenia and during saline infusion

The effects of calcium-gluconate infusions on renal function were studied in unanesthetised dogs. Each dog was studied during hydropenia and saline infusion. Hypercalcemia, mean serum calcium 3.85 mmol/l (hydropenia) and 3.62 mmol/l (saline infusion), increased fractional excretion of sodium (CNa/CIn), calcium (CCa/CIn), and magnesium (CMg/CIn). The increase was significantly higher in saline-expanded dogs than in hydropenic dogs. Fractional excretion of potassium (CK/CIn) was increased in hydropenia but remained unchanged in saline-expanded animals. Fractional excretion of phosphate (Cp/CIn) was not consistently changed by hypercalcemia. Fractional excretion of chloride (CCl/CIn) was markedly increased in saline-expanded dogs but was not changed in hydropenia. Urine osmolality was reduced in hydropenic dogs but unchanged in saline-expanded dogs. In hydropenic as well as in saline-expanded dogs tubular reabsorption of solute-free water (TcH2O/CIn) increased during the first hour of hypercalcemia. In hydropenic dogs hypercalcemia caused a slight but significant decrease in blood pH, standard bicarbonate, and base excess. In hydropenic as well as in saline-expanded dogs glomerular filtration rate (CIn), renal plasma flow (CPAH), and filtration fraction were unaffected.

Evidence for a parathyroid hormone-dependent influence of calcium on the glomerular ultrafiltration coefficient

Experiments were performed on 36 plasma-expanded Munich-Wistar rats to examine the effects of acute hypercalcemia on the determinants of glomerular ultrafiltration. Elevation of total plasma calcium concentration to an average value of 13.2 +/- 0.5 mg/dl, by acute infusion of calcium chloride into nonthyroparathyroidectomized (non-TPTX) rats, resulted in significant declines in single nephron and whole kidney glomerular filtration rate. These declines were due primarily to a fall in the glomerular capillary ultrafiltration coefficient (Kf), to a mean value approximately 60% below that determined in the pre-infusion period. These changes were not seen in a separate group of sham-treated non-TPTX rats. It is of interest that these effects of acute hypercalcemia were largely abolished in rats that underwent acute TPTX before hypercalcemia. Infusion of a submaximally phosphaturic dose of parathyroid hormone, together with calcium chloride, into a second group of acute TPTX rats, however, had the effect of reproducing the striking declines in filtration rate and Kf noted in non-TPTX rats given calcium chloride alone. These findings suggest that the decline in filtration rate associated with hypercalcemia is due largely to the reduction in Kf, the latter dependent upon the presence of parathyroid hormone.

On the mechanism of polyuria in potassium depletion. The role of polydipsia

The association of potassium (K) depletion with polyuria and a concentrating defect is established, but the extent to which these defects could be secondary to an effect of low K on water intake has not been systematically investigated. To determine whether hypokalemia has a primary effect to increase thirst and whether any resultant polyuria and polydipsia contribute to the concentrating defect, we studied three groups of rats kept in metabolic cages for 15 days. The groups were set up as follows: group 1, normal diets and ad lib. fluids (n = 12); group 2, K-deficient diet on ad lib. fluids (n = 12); and group 3, K-deficient diet and fluid intake matched to group 1 (n = 14). Daily urine flow and urinary osmolality of groups 1 and 3 were not significantly different throughout the study. In contrast, as of day 6, group 2 rats consistently had a higher fluid intake (P < 0.0025), higher urine flow (P < 0.001), and lower urinary osmolality (P < 0.001) than the other two groups. These alterations in fluid intake and urine flow preceded a defect in maximal concentrating ability. On day 7, maximal urinary osmolality was 2,599+/-138 msmol/kg in rats on K-deficient intake and 2,567+/-142 msmol/kg in controls. To determine whether this primary polydipsia is itself responsible for the development of the concentrating defect, the three groups of rats were dehydrated on day 15. Despite different levels of fluid intake, maximal urinary osmolality was impaired equally in groups 2 and 3 (1,703 and 1,511 msmol/kg, respectively), as compared to rats in group 1 (2,414 msmol/kg), P < 0.001. We therefore conclude that K depletion stimulates thirst, and the resultant increase in water intake is largely responsible for the observed polyuria. After 15 days of a K-deficient diet, the impaired maximal urinary concentration in hypokalemia, however, was not related to increased water intake, since fluid restriction did not abolish the renal concentrating defect.

Effects of hypercalcemia on water and sodium excretion by the isolated dog kidney

The effects of acute hypercalcemia on hemodynamics and on water and sodium excretion were studied on the blood-perfused isolated dog kidney. This model advantageously eliminates various factors which modify medullary osmolality and intrarenal hemodynamics, as well as collecting duct permeability. Calcium ion directly inhibits sodium reabsorption in the proximal tubule and in the ascending limb of Henle's loop, leading to increased sodium excretion rate and to decreased free water generation. The vasoconstrictive action of calcium, leading to decreased glomerular filtration rate, may mitigate the strong natriuretic effect of this ion.