Effect of posture on clearance of atrial natriuretic peptide from plasma

Raised plasma levels of atrial natriuretic factor in cardiac allograft recipients: evidence of increased cardiac secretion and decreased renal clearance

The mechanism(s) causing high levels of plasma atrial natriuretic factor (ANF) in cardiac allograft recipients is(are) unclear. The kidney is important for the clearance of ANF and renal function may decline with cyclosporin A therapy in these patients. The relationship between plasma ANF level and renal function and also the pharmacokinetics of a continuous infusion of ANF (15.5 ng.kg-1.min-1 for 60 min) was examined in 6 cardiac allograft recipients on cyclosporin A therapy. Resting plasma ANF levels were significantly higher in these patients than in 8 healthy subjects (71 vs. 21 ng.l-1). Both effective renal plasma flow (ERPF) and glomerular filtration rate (GFR) were significantly lower in these patients than in healthy subjects (215 vs. 617 ml.min-1 and 55 vs. 102 ml.min-1 respectively). There was a significant inverse correlation between plasma ANF and ERPF (r = -0.86) and between plasma ANF and GFR (r = -0.81). During the period of ANF infusion, steady state plasma ANF levels were significantly higher in cardiac allograft recipients. Total body clearance of ANF was marginally lower in these patients than in healthy subjects (60 vs. 10.0 l.min-1) although this difference did not reach statistical significance. Derived endogenous secretion rate of ANF was threefold higher in patients when compared to healthy subjects (633 vs. 208 ng.min-1). We have therefore shown that cardiac allograft recipients on cyclosporin A have elevated plasma ANF levels and also decreased renal function. Pharmacokinetic analysis have shown that this increase in plasma ANF levels is due more to increased ANF secretion than to decreased ANF clearance in these patients.

The antidiuretic effect of pneumadin requires a functional arginine vasopressin system

Pneumadin is an antidiuretic decapeptide, recently isolated from rat and human lung. Bolus intravenous injection of 5 nmol of pneumadin into water-loaded rats caused a rapid and significant antidiuresis and a reduction in Na+ and Cl- excretion. Pneumadin administration did not alter mean arterial pressure, right atrial pressure, heart rate or haematocrit. Bolus intravenous injection of 20 nmol of pneumadin into non-water-loaded rats caused a significant increase in arginine vasopressin (AVP) within 10 min. Pneumadin administration also increased circulating atrial natriuretic peptide (ANP) but did not alter aldosterone or plasma renin activity levels. Injection of pneumadin into water-loaded Brattleboro rats, which genetically lack circulating AVP, did not change urine flow, confirming that the pneumadin induced antidiuresis is AVP dependent. Radioactive pneumadin was cleared from the circulation with a t1/2 beta of 480.3 s. Radioactive pneumadin, isolated from plasma, eluted at an altered position on reverse phase HPLC, which indicated that the peptide was modified in vivo. This modification was also observed when synthetic pneumadin was incubated in rat plasma in vitro. Purification and sequencing of the modified synthetic peptide indicated that the modification is not a proteolytic cleavage. These results indicate that pneumadin injected into the rat caused an antidiuresis by altering circulating AVP levels.

Pharmacokinetics and effects of atrial natriuretic factor during hypothermic cardiopulmonary bypass

The pharmacokinetics of a bolus dose of synthetic atrial natriuretic factor (ANF) 50 micrograms and its effects on urine output, blood pressure and plasma renin activity have been studied in 5 patients undergoing hypothermic cardiopulmonary bypass for cardiac surgery. The half-lives of the fast and slow components were 2.4 min and 14.2 min, respectively. The volume of the central compartment was 16.7 l and the volume of distribution at steady-state was 38.9 l. The total plasma clearance was 3.8 l.min-1. ANF significantly increased urine output and decreased blood pressure, but it did not affect plasma renin activity.

Atrial natriuretic factor: its (patho)physiological significance in humans

The first human studies using relatively high-doses of ANF revealed similar effects as observed in the preceding animal reports, including effects on systemic vasculature (blood pressure fall, decrease in intravascular volume), renal vasculature (rise in GFR, fall in renal blood flow), renal electrolyte excretion (rises in many electrolytes), and changes in release of a number of different hormones. Whether all these changes are the result of direct ANF effects or secondary to a (single) primary event of the hormone remains to be determined. Certainly, it has been proven that more physiological doses of ANF fail to induce short-term changes in many of these parameters leaving only a rise in hematocrit, natriuresis and an inhibition of the RAAS as important detectable ANF effects in humans. This leads us to hypothesize that ANF is a "natriuretic" hormone with physiological significance. The primary function in humans is to regulate sodium homeostasis in response to changes in intravascular volume (cardiac atrial stretch). Induction of excess renal sodium excretion and extracellular volume shift appear to be the effector mechanisms. The exact mechanism of the natriuresis in humans still needs to be resolved. It appears however, that possibly a small rise in GFR, a reduction in proximal and distal tubular sodium reabsorption, as well as an ensuing medullary washout, are of importance. The pathophysiological role of ANF in human disease is unclear. One may find elevated plasma irANF levels and/or decreased responses to exogenous ANF in some disease states. Whether these findings are secondary to the disease state rather than the cause of the disease remains to be resolved. Therapeutic applications for ANF, or drugs that intervene in its production or receptor-binding, seem to be multiple. Most important could be the antihypertensive effect, although areas such as congestive heart failure, renal failure, liver cirrhosis and the nephrotic syndrome cannot be excluded. Although the data that have been gathered to date allowed us to draw some careful conclusions as to the (patho)physiological role of ANF, the exact place of ANF in sodium homeostatic control must still be better defined. To achieve this, we will need more carefully designed low-dose ANF infusion, as well as ANF-breakdown inhibitor studies. Even more promising, however, is the potential area of studies open to us when ANF-receptor (ant)agonists become available for human use.

Regulation of ANP secretion in insulin-dependent diabetes mellitus and the influence of autonomic neuropathy

In order to determine the effect of diabetic autonomic neuropathy (DAN) on the atrial natriuretic peptide (ANP) response to dynamic stimuli, we studied the ANP response to 60 degrees head-up and 60 degrees leg-up tilt in diabetic subjects with (DAN + ve, n = 8) and without (DAN - ve, n = 8) evidence of autonomic neuropathy and seven matched non-diabetic controls. Mean baseline plasma ANP concentrations were similar in all three groups. Head-up tilt was associated with a fall in plasma ANP in all seven healthy controls (21.8 (16.8-30.7) to 16.8 (7.1-29.1), P = 0.06, mean (range)), seven of the eight DAN - ve (16.9 (6.5-33.7) to 8.5 (3.0-21.1), P = 0.015) and all eight DAN + ve subjects (27.3 (8.5-101.5) to 15.4 (1.0-67.6), P = 0.044). Leg-up tilt caused a rise in plasma ANP in six of the seven healthy controls (17.6 (7.5-27.9) to 22.4 (15.2-48.1), P = 0.041), six of the eight DAN - ve (12.5 (7.8-27.8) to 15.5 (7.3-31.3), P = 0.054) and seven of the eight DAN + ve subjects (18.2 (2.8-55.1) to 25.1 (4.5-92.8), P = 0.013). There was no significant difference in the fall in plasma ANP during head-up tilt or in the rise in plasma ANP during leg-up tilt between the three groups. We conclude that the regulation of ANP secretion is normal in diabetes mellitus, and is unaffected by the presence of autonomic neuropathy.

Regulation of atrial natriuretic peptide release in pregnancy: responses to posture

The response of plasma atrial natriuretic peptide to three changes in posture that alter atrial stretch was examined in the late phase of pregnancy: (1) after 20 minutes in lateral recumbency, remaining upright for 2 hours decreased median plasma atrial natriuretic peptide values from 37.8 (25th percentile, 22.9 and 75th percentile; 64.2) to 21.8 (10.1 and 28.4) pg/ml in pregnant women (p less than 0.05) and from 39.2 (27.8 and 51.2) to 24.0 (18.9 and 35.4) pg/ml (p less than 0.001) in age-matched nonpregnant women; (2) prolongation of lateral recumbency from 20 to 80 minutes increased median plasma atrial natriuretic peptide levels from 31.9 (25.6 and 37.3) to 47.8 (33.0 and 74.6) pg/ml in pregnant women (p less than 0.001) and from 36.5 (22 and 58.6) to 54.0 (36.3 and 111.7) pg/ml in nonpregnant women (p less than 0.01); (3) adoption of supine posture during the late phase of normal pregnancy did not alter median plasma atrial natriuretic peptide values significantly [30.4 (26.7 and 42.5) pg/ml during lateral recumbency compared with 34.2 (25.4 and 43.5) pg/ml while supine]. Plasma atrial natriuretic peptide values fell after supine posture in only half the women and supine hypotension occurred in one subject. These studies demonstrate that upright and prolonged lateral recumbent postures significantly influence plasma atrial natriuretic peptide values during pregnancy, as they do in the nonpregnant state, but that supine posture does not alter plasma atrial natriuretic peptide values significantly. Posture must be carefully accounted for in any study of plasma atrial natriuretic peptide in pregnancy.

The influence of supine relaxation on blood pressure, heart rate and atrial natriuretic peptide in normal subjects

The effect of recumbent rest on plasma atrial natriuretic peptide (ANP) concentration, mean blood pressure (MBP) and heart rate was studied in 26 normal human volunteers. Plasma ANP concentration, MBP and heart rate were determined after 10 min sitting and after 2, 5, 8, 15 and 30 min of recumbency. During the first 5 min of recumbency there were significant decreases in both MBP (p less than 0.001) and heart rate (p less than 0.001) compared with sitting. There was a small but significant fall in plasma ANP concentration (p = 0.02) after 30 min of recumbency compared with sitting. No further reduction in MBP or heart rate occurred after 5 min supine. The level of MBP following 5 min supine correlated significantly (r = 0.44; p = 0.02) with the plasma ANP concentration 25 min later. Blood pressure and heart rate are highly dependent on posture and relaxation, and plasma ANP concentration in lesser degree. It is necessary to wait for stable baseline values to develop before any comparisons between blood pressure and plasma ANP are done. If it is assumed that a causative relation exists between blood pressure and plasma ANP level, it appears there may be a delay of 20-30 min between a change in blood pressure and the physiological response of plasma ANP level. This observation may have implications for the interpretation of the relation between blood pressure and plasma ANP concentration in healthy individuals.

Elevated atrial natriuretic factor in the plasma: cause or effect in "idiopathic orthostatic hypotension"?

A patient with idiopathic orthostatic hypotension exhibited low activity of norepinephrine and renin in plasma which failed to respond to standing. Levels of atrial natriuretic factor were inappropriately elevated and failed to fall on standing. The possible role of the atrial natriuretic factor in idiopathic orthostatic hypotension is discussed.

Renal disposal of human atrial natriuretic peptide in man

In healthy men (n = 7) the renal fractional extraction of human atrial natriuretic factor (hANP) as determined by the renal venous catheter technique was approximately 50% both under basal conditions and during the administration of exogenous hANP. When arterial and venous plasma concentrations of hANP were maintained about tenfold above basal concentrations by a bolus- (100 micrograms) primed intravenous (IV) infusion (100 micrograms/h for 1 hour) of hANP, renal uptake of hANP increased from, basal, 11.2 +/- 6.7 pmol/min to 126.5 +/- 64.8 pmol/min (P less than .05), while estimated renal plasma flow (ERPF) decreased by about 25% (P less than .05). Total metabolic clearance rates (MCRs) of hANP, renal clearance rates, and production rates of hANP were 3.89 +/- 1.21 L/min, 0.42 +/- 0.18 L/min, and 76.1 +/- 52.7 pmol/min, respectively. In healthy men, one kidney accounts for about 10% of total hANP clearance.

Interaction of angiotensin converting enzyme inhibition and atrial natriuretic factor

The interaction of angiotensin converting enzyme (ACE) inhibition and atrial natriuretic factor (ANF) was investigated in six supine, sodium-replete, normal volunteers who received captopril (10 mg i.v. bolus followed by 10 mg/hr constant infusion) or vehicle superimposed on background 3-hour, constant, low-dose (1.5 pmol/kg/min) infusions of human ANF (99-126). Plasma converting enzyme activity was significantly inhibited but this had no effect on endogenous plasma ANF concentrations. ANF infusions, with or without captopril, caused similar increases in plasma ANF concentrations, and calculated metabolic clearance rates for ANF were unchanged. Similarly, blood pressure, heart rate, renal blood flow, glomerular filtration rate, and renal electrolyte excretion, including ANF-induced natriuresis, were unaffected by captopril. The combination of ANF plus captopril produced a significant increase in plasma aldosterone (79 +/- 8 vs. 60 +/- 6 pmol/l, p less than 0.05), cortisol (406 +/- 52 vs. 265 +/- 29 nmol/l, p less than 0.01), adrenaline (119 +/- 21 vs. 76 +/- 10 pg/ml, p less than 0.05), and noradrenaline (319 +/- 49 vs. 215 +/- 38 pg/ml, p less than 0.05) compared with time-matched placebo data. Converting enzyme inhibition, in the absence of major changes in blood pressure or renal blood flow, has little effect on ANF metabolism or renal bioactivity. However, ACE inhibition and ANF combined may interact to increase activity of the hypothalamo-pituitary-adrenal axis and sympathetic nervous system by unknown mechanisms.

Atrial natriuretic factor in human pathophysiology

1. Evidence from numerous experiments incorporating central blood volume expansion and changes in sodium status supports atrial stretch as the prime determinant of ANF release. 2. Plasma ANF levels are the result of both secretion and clearance of the peptide. Clearance is altered by a number of factors, including changes in posture in normal man and is probably impaired in disease states with diminished renal and hepatic blood flow. 3. In normal subjects an inverse relationship exists between plasma ANF values and renin-angiotensin-aldosterone system activity. This relationship is lost and replaced by a positive association in heart failure, presumably reflecting the abnormal concurrence of increased atrial stretch and diminished renal perfusion in this condition. Plasma ANF values rise with increasing severity of heart failure and fall with effective treatment. 4. Plasma ANF values are elevated in hypertension and cardiac tachyarrhythmias possibly reflecting raised central venous and atrial pressures. 5. A variety of other disorders may be associated with abnormal plasma ANF values including cirrhosis and the syndrome of inappropriate ADH secretion. 6. Evidence from low-dose infusions of ANF in normal volunteers suggests that the variations in plasma ANF seen in health and disease are sufficient to exert biological effects. 7. The advent of a specific antagonist is needed to provide further insight into the physiological and pathophysiological roles of ANF.