Effect of geography on the use of ultrafiltration during cardiac surgery with cardiopulmonary bypass

BACKGROUND

Ultrafiltration (UF) is a common practice during cardiopulmonary bypass (CPB) where it is used as a blood management strategy to reduce red blood cell (RBC) transfusion, minimize adverse effects of hemodilution, and reduce proinflammatory mediators. However, its clinical utilization has been shown to vary throughout the continents.

PURPOSE

The purpose of this investigation was to assess the distribution of UF use across the United States.

DATA COLLECTION

Data on UF use during cardiac surgery was obtained from a national (United States) perfusion database for adult cardiac procedures performed from January 2016 through December 2018.

STUDY SAMPLE

Four geographical regions were established: Northeast (NE), South (SO), Midwest (MW) and West (WE). The primary endpoint was the use of UF with secondary endpoints UF volume, CPB and anesthesia asanguineous volumes, intraoperative allogeneic RBC transfusion, nadir hematocrit and urine output (UO). 92,859 adult cardiac cases from 191 hospitals were reviewed.

RESULTS

The NE and the WE had similar usages of UF (59.9% and 59.7% respectively), which were higher than the MW and the SO (38.6% and 34.9%, p < .001). When UF was utilized, the median [IQR] volume removed was highest in the NE (1900 [1200-2800]mL), and similar in all other regions (WE 1500 [850-2400 mL, MW 1500 [900-2300]mL and SO 1500 [950-2200]mL, p < .001. Median total UO was lowest in the NE 400 [210,650]mL vs all other regions (p < .001), and remained so when indexed by patient weight and operative time (NE-0.8 [0.5, 1.3]mL/kg/hour, MW-1.1 [0.7, 1.8] mL/kg/hour, SO-1.3 [0.8, 2.0]mL/kg/hour, WE-1.1 [0.7, 1.3]mL/kg/hour, p < .001. Intraoperative RBC transfusion rate was highest in the SO (21.3%) and WE (20.5%), while similar rates seen in the NE (16.2%) and MW (17.6%), p < .001.

CONCLUSIONS

Across the United States there is geographic variation on the use of UF. Further research is warranted to investigate why these practice variations exist and to better understand and determine their reasons for use.

Establishment of a national quality improvement process on oxygen delivery index during cardiopulmonary bypass

Targeted oxygen delivery during cardiopulmonary bypass (CPB) has received significant attention due to its influence on patient outcomes, especially in mitigating acute kidney injury. While it has gained popularity in select institutions, there remains a gap in establishing it globally across multiple centers. The purpose of this investigation was to describe the development of a quality improvement process of targeted oxygen delivery during CPB across hospitals throughout the United States. A systematic approach to utilize oxygen delivery index (DO2i) as a key performance indicator within hospitals serviced by a national provider of perfusion services. The process included a review of the current literature on DO2i, which yielded a target nadir value (272 mL/min/m2) and an area under the curve (DO2i272AUC) cut off of 632. All data is displayed on a dashboard with results categorized across multiple levels from system-wide to individual clinician performance. From January 2020 through December 2022, DO2i data from 91 hospitals and 11,165 coronary artery bypass graft procedures were collected. During this period the monthly proportion of DO2i measurements above the target nadir DO2i272 ranged from 60.5% to 78.4% with a mean+/-SD of 70.8 +/- 4.2%. Binary logistic regression for the first 7 months following monthly DO2i performance reporting has shown a statistically significant positive linear trend in the probability of achieving the target DO2i272 (p < .001), with a crude increase of approximately 7.8% for DO2i272AUC, and a 73.8% success rate (p < .001). A survey was sent to all individuals measuring oxygen delivery during CPB to assess why a target DO2i272 could not be reached. The two most common responses were an 'inability to improve CPB flow rates' and 'restrictive allogeneic red blood cell transfusion policies'. This study demonstrates that targeting a minimum level of oxygen delivery can serve as a key performance indicator during CPB using a structured quality improvement process.

Extracellular volume fraction by computed tomography predicts long-term prognosis among patients with cardiac amyloidosis

Objective

This study sought to investigate the association of extracellular volume fraction by computed tomography (ECVCT), myocardial remodeling and mortality in patients with systemic amyloidosis.

Background

Light chain (AL) and transthyretin (ATTR) amyloid fibrils are deposited in the extracellular space of the myocardium, resulting in heart failure and premature mortality. Extracellular expansion can be quantified by CT, offering a rapid and cost-effective alternative to cardiovascular magnetic resonance (CMR), especially among patients with cardiac devices or on renal dialysis.

Methods

Patients with confirmed systemic amyloidosis and varying degrees of cardiac involvement underwent ECG-gated cardiac CT. ECVCT was analysed in the inter-ventricular septum. All patients also underwent clinical assessment, ECG, echocardiography, serum amyloid protein component (SAP) and/or technetium-99m (99mTc) 3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy. ECVCT was compared across different extents of cardiac infiltration (ATTR Perugini Grade / AL Mayo Class) and evaluated for its association with myocardial remodelling and all-cause mortality.

Results

72 patients were studied (AL n=35, ATTR n=37; age 67 (59–76) years, 71% males). Mean septal ECVCT was 42.7±13.1% and 55.8±10.9% in AL and ATTR, respectively, and correlated with indexed left ventricular (LV) mass (r=0.426, p&lt;0.001), LV ejection fraction [LVEF, (r=0.460, p&lt;0.001)], NT-proBNP (r=0.563, p&lt;0.001) and hsTnT (r=0.546, p=0.02). ECVCT increased with cardiac amyloid involvement in both AL and ATTR (Figure 1). Over a mean follow-up of 5.3±2.4 years, 40 deaths occurred (AL 14 [35%]; ATTR 26 [65%]). ECVCT was independently associated with all-cause mortality in ATTR (not AL) after adjustment for age and IV septal wall thickness (HR: 1.046, 95% CI: 1.003–1.090, p=0.037).

Conclusion

Cardiac amyloid burden quantified by ECVCT is associated with adverse cardiac remodelling as well as all-cause mortality among ATTR amyloid patients. ECVCT may address the need for better identification and risk stratification of amyloid patients, using a widely-accessible imaging modality (Figure 2).

Funding Acknowledgement

Type of funding sources: None.

Outcomes of trans-catheter versus surgical aortic valve replacement for patients with classic low-flow low-gradient aortic stenosis

Background

Classical low-flow low-gradient aortic stenosis (cLFLG-AS) is frequently encountered within clinical practice [1], and is often associated with high mortality [2]. Whilst aortic valve replacement can improve outcomes, there is a lack of real-world data guiding the decision between trans-catheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) in this specific patient cohort.

Purpose

To compare outcomes between TAVI and SAVR in patients with cLFLG-AS.

Methods

cLFLG-AS was defined by an aortic valve area &lt;1cm2, mean gradient &lt;40mmHg or peak velocity &lt;4m/s and left ventricular ejection fraction &lt;50%. All patients who met cLFLG-AS criteria who underwent TAVI or SAVR at our tertiary referral centre between 2015 and 2020 were included. Inverse probability weighting was used to adjust for differences in baseline characteristics and the non-random assignment of treatment modalities. The primary end-point was all-cause mortality. Secondary end-points were procedure-related permanent pacemaker implantation, renal replacement therapy (RRT) and stroke.

Results

322 patients were included (220 TAVI and 102 SAVR). Baseline characteristics were: male sex 70%, mean gradient 30mmHg (23–35), aortic valve area 0.8cm2 (0.6–0.9). Patients undergoing TAVI were older than the SAVR group (81.3±8.5 vs 70.6±11.1 years, p&lt;0.0001) with higher Logistic Euroscore (19.3 (11.8–32.3) vs 7.1 (3.7–14.1), p&lt;0.0001) (figure 1).

At median follow-up of 2.7 years (1.5–4.1), 99 patients had died; 70 (31.8%) had TAVI and 29 (28.4%) had SAVR. Both unweighted and weighted Kaplan-Meier curve analysis was performed; there was similar survival between SAVR and TAVI (log rank test 0=0.27 and p=0.4 respectively) (figure 2).

Adjusted hazard ratio (HR) for mortality with SAVR was 0.78 unweighted (95% CI 0.5–1.21; p=0.27) and 0.66 weighted (95% CI 0.26–1.64; p=0.37).

In terms of contributory procedural factors, concomitant multiple valve intervention in the SAVR group independently affected mortality (HR 5.47, 95% CI 2.52–11.51, p&lt;0.001).

There was no difference in permanent pacemaker insertion or stroke across the two groups, but rates of RRT were higher in SAVR cohort (13.7% vs 0%, p&lt;0.001).

Conclusions

Despite the TAVI cohort being both older and at higher risk, there was no observed difference in mortality between TAVI and SAVR in the mid-term. Deciding upon intervention choice can therefore be based upon criteria other than the specific presence of a classic low-flow low-gradient state.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Clinical training research fellowship from the British Heart Foundation Baseline characteristics by treatmentKaplan-Meier curves for TAVI vs SAVR

The assessment of patients undergoing cardiac surgery for Covid-19: Complications occurring during cardiopulmonary bypass

The outbreak of the novel coronavirus pandemic (COVID-19) has resulted in dramatic changes to the conduct of surgery both from a patient management perspective and in protecting healthcare providers. The current study reports on the status of COVID-19 infections in patients presenting for cardiac surgery with cardiopulmonary bypass (CPB) on circuit complications. A tracking process for monitoring the presence of COVID-19 in adult cardiac surgery patients was integrated into a case documentation system across United States hospitals where out-sourced perfusion services were provided. Assessment included infection status, testing technique employed, surgery status and CPB complications. Records from 5612 adult patients who underwent cardiac surgery between November 1, 2020 and January 18, 2021 from 176 hospitals were reviewed. A sub-cohort of coronary artery bypass graft patients (3283) was compared using a mixed effect binary logistic regression analysis. 4297 patients had negative test results (76.6%) while 49 (0.9%) tested positive for COVID-19, and unknown or no results were reported in 693 (12.4%) and 573 (10.2%) respectively. Coagulation complications were reported at 0.2% in the negative test results group versus 4.1% in the positive test result group (p < 0.001). Oxygenator gas exchange complications were 0.2% in the negative test results group versus 2.0% in the positive test results group (p = 0.088). Coronary artery bypass graft patients with a positive test had significantly higher risk for any CPB complication (p = 0.003) [OR 10.38, CI 2.18–49.53] then negative test patients [OR 0.01, CI 0.00–0.20]. The present study has shown that patients undergoing cardiac surgery with CPB who test positive for COVID-19 have higher CPB complication rate than those who test negative.

Comparative evaluation of isoflurane and sevoflurane in avian patients

Background and Aim:

Literature comparing the use of isoflurane and sevoflurane inhalation anesthetic agents in birds is scarce. This study aimed to evaluate the comparison of isoflurane and sevoflurane during induction, maintenance, and recovery of anesthesia in avian patients.

Materials and Methods:

In this study, 24 injured avian patients (n=24) were selected randomly and divided into four groups during kite flying festival. In the present study, isoflurane and sevoflurane were used as induction and maintenance anesthetic agents, with and without butorphanol tartrate premedication agent in all the birds. Different physiological parameters were evaluated, namely, cloacal temperature (°F), heart rate (beats/min), respiratory rate (breaths/min), and SpO₂ (%) were recorded at 0, 10, 20 min, and at recovery time. The quality of anesthesia was assessed on the basis of induction time, quality of induction, production of analgesia, muscle relaxation, body reflexes, recovery time, quality of recovery, sitting, standing, and complete recovery time (CRT).

Results:

The mean±standard error value of induction time was 230.00±32.55, 280.00±25.29, 180.00±21.90, and 260.00±36.87 s, respectively, in Groups I, II, III, and IV. The feather plucking, pharyngeal, and toe pinching reflexes were noticed, when the birds were passing through the light plane of anesthesia during induction. Comparison of cloacal temperature at the time of recovery between Group-I versus Group-III revealed a significant difference (p<0.05). Comparison of mean respiratory rates at the time of recovery between Group-II versus Group-IV revealed a significant difference (p<0.05). Excellent quality of recovery was observed in all the groups of anesthetic protocols. Sitting, standing, and CRT were observed shortest in avian patients maintained with sevoflurane as compared to isoflurane.

Conclusion:

The quality of induction of anesthesia was rapid in avian patients when induced with sevoflurane as compared to isoflurane. Rapid onset of induction and recovery of anesthesia were found with sevoflurane followed by isoflurane. Induction and maintenance of anesthesia in avian patients with sevoflurane resulted in the lowest time required for sitting, standing, and CRT.

Myocardial fibrosis quantification by cardiac CT predicts outcome in severe aortic stenosis

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

Myocardial extracellular volume (ECV) increases with fibrosis, oedema or infiltration. ECV by CMR predicts all-cause and cardiovascular mortality in severe AS after valve intervention. Previous studies have shown that ECV can be reliably quantified by computed tomography (ECVCT), but these studies have not differentiated between ECV elevation due to fibrosis or cardiac amyloid deposition (13-16% of patients with severe AS). 

Purpose

We hypothesised that ECVCT quantification, performed as part of a transcatheter aortic valve implantation (TAVI) work-up CT, predicts survival in patients with severe AS without cardiac amyloid (lone AS).

Methods

Patients aged ≥75, with severe AS, referred for TAVI at Barts Heart Centre (as part of ATTRact-AS (NCT03029026)) underwent CT as part of their clinical work-up. All patients had 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy and those with a positive result were excluded.  CT was performed on a 128-slice dual-source 3rdgeneration scanner (Siemens Somatom FORCE) and ECVCT was acquired during the TAVI work-up CT using additional pre- and 3-minute post-contrast ‘axial shuttle mode’ acquisitions (no additional contrast).  ECVCT was calculated from the Hounsfield units (HU) and a venous haematocrit (HCT): ECVCT = (1-HCT) x (ΔHUmyo/ΔHUblood).

Results

Following exclusion of 16 patients with cardiac uptake on DPD, 93 patients (41% male, aged 85 ± 5 years) were included in the study.  All patients had severe AS (AV Vmax 4.12 ± 0.63m/s, mean AV gradient 42 ± 14mmHg, AVA 0.71 ± 0.23cm2). The mean HCT was 0.38 ± 0.04 and total dose-length product for additional research scans was 364 ± 41 mGy.cm. 76 patients (82%) underwent TAVI. ECVCT was 32 ± 3% in the entire cohort, which we then split into those with a ‘higher’ ECVCT (&gt;34%, n = 23, representing the highest quartile) and those with a ‘lower’ ECVCT (≤34%, n = 70, representing the lower quartiles). Over a median follow-up of 25 months (IQR 17-34 months) there were 27 deaths (29%), of whom 11 did not undergo TAVI (41%). There were 10 deaths in the 23 patients (44%) with a higher ECVCT, compared to 17 in the 70 patients (24%) with a lower ECVCT (p = 0.03, figure 1). This mortality difference remained significant when those patients who did not undergo TAVI were excluded (p = 0.03).

Conclusions

Myocardial fibrosis quantified by ECVCT is associated with a significantly worse prognosis in lone AS, even after patients with AS-amyloid are excluded. ECVCT can be performed as a simple addition to the TAVI work-up CT and provides additional prognostic information.

Abstract Figure.

Structural basis of acquired resistance to selpercatinib and pralsetinib mediated by non-gatekeeper RET mutations

BACKGROUND

Selpercatinib (LOXO-292) and pralsetinib (BLU-667) are highly potent RET-selective protein tyrosine kinase inhibitors (TKIs) for treating advanced RET-altered thyroid cancers and non-small-cell lung cancer (NSCLC). It is critical to analyze RET mutants resistant to these drugs and unravel the molecular basis to improve patient outcomes.

PATIENTS AND METHODS

Cell-free DNAs (cfDNAs) were analyzed in a RET-mutant medullary thyroid cancer (MTC) patient and a CCDC6-RET fusion NSCLC patient who had dramatic response to selpercatinib and later developed resistance. Selpercatinib-resistant RET mutants were identified and cross-profiled with pralsetinib in cell cultures. Crystal structures of RET-selpercatinib and RET-pralsetinib complexes were determined based on high-resolution diffraction data collected with synchrotron radiation.

RESULTS

RETG810C/S mutations at the solvent front and RETY806C/N mutation at the hinge region were found in cfDNAs of an MTC patient with RETM918T/V804M/L, who initially responded to selpercatinib and developed resistance. RETG810C mutant was detected in cfDNAs of a CCDC6-RET-fusion NSCLC patient who developed acquired resistance to selpercatinib. Five RET kinase domain mutations at three non-gatekeeper residues were identified from 39 selpercatinib-resistant cell lines. All five selpercatinib-resistant RET mutants were cross-resistant to pralsetinib. X-ray crystal structures of the RET-selpercatinib and RET-pralsetinib complexes reveal that, unlike other TKIs, these two RET TKIs anchor one end in the front cleft and wrap around the gate wall to access the back cleft.

CONCLUSIONS

RET mutations at the solvent front and the hinge are resistant to both drugs. Selpercatinib and pralsetinib use an unconventional mode to bind RET that avoids the interference from gatekeeper mutations but is vulnerable to non-gatekeeper mutations.

Combining an epithelial repair factor and anti-fibrotic with a corticosteroid offers optimal treatment for allergic airways disease

BACKGROUND AND PURPOSE

We evaluated the extent to which individual versus combination treatments that specifically target airway epithelial damage [trefoil factor-2 (TFF2)], airway fibrosis [serelaxin (RLX)] or airway inflammation [dexamethasone (DEX)] reversed the pathogenesis of chronic allergic airways disease (AAD).

EXPERIMENTAL APPROACH

Following induction of ovalbumin (OVA)-induced chronic AAD in 6–8 week female Balb/c mice, animals were i.p. administered naphthalene (NA) on day 64 to induce epithelial damage, then received daily intranasal administration of RLX (0.8 mg·mL(−1)), TFF2 (0.5 mg·mL(−1)), DEX (0.5 mg·mL(−1)), RLX + TFF2 or RLX + TFF2 + DEX from days 67–74. On day 75, lung function was assessed by invasive plethysmography, before lung tissue was isolated for analyses of various measures. The control group was treated with saline + corn oil (vehicle for NA).

KEY RESULTS

OVA + NA-injured mice demonstrated significantly increased airway inflammation, airway remodelling (AWR) (epithelial damage/thickness; subepithelial myofibroblast differentiation, extracellular matrix accumulation and fibronectin deposition; total lung collagen concentration), and significantly reduced airway dynamic compliance (cDyn). RLX + TFF2 markedly reversed several measures of OVA + NA-induced AWR and normalized the reduction in cDyn. The combined effects of RLX + TFF2 + DEX significantly reversed peribronchial inflammation score, airway epithelial damage, subepithelial extracellular matrix accumulation/fibronectin deposition and total lung collagen concentration (by 50–90%) and also normalized the reduction of cDyn.

CONCLUSIONS AND IMPLICATIONS

Combining an epithelial repair factor and anti-fibrotic provides an effective means of treating the AWR and dysfunction associated with AAD/asthma and may act as an effective adjunct therapy to anti-inflammatory corticosteroids

Intranasally administered serelaxin abrogates airway remodelling and attenuates airway hyperresponsiveness in allergic airways disease

BACKGROUND

The peptide hormone relaxin plays a key role in the systemic hemodynamic and renovascular adaptive changes that occur during pregnancy, which is linked to its antiremodelling effects. Serelaxin (a recombinant form of human gene-2 relaxin) has been shown to inhibit lung fibrosis in various disease models and reverse airway remodelling and airway hyperresponsiveness (AHR) in allergic airways disease (AAD).

OBJECTIVE

Although continuous systemic delivery of exogenous serelaxin alleviates allergic fibrosis and AHR, more direct routes for administration into the lung have not been investigated. Thus, intranasal administration of serelaxin was evaluated for its ability to reverse airway remodelling and AHR associated with AAD.

METHODS

Female Balb/c mice were subjected to a 9-week model of chronic AAD. Subgroups of animals (n = 12/group) were then treated intranasally with serelaxin (0.8 mg/mL) or vehicle once daily for 14 days (from weeks 9-11). Saline-sensitized/challenged mice treated with intranasal saline served as additional controls. Differential bronchoalveolar lavage (BAL) cell counts, ovalbumin (OVA)-specific IgE levels, tissue inflammation, parameters of airway remodelling and AHR were then assessed.

RESULTS

Chronic AAD was associated with significant increases in differential BAL cell counts, OVA-specific IgE levels, inflammation, epithelial thickening, goblet cell metaplasia, TGF-β1 expression, epithelial Smad2 phosphorylation (pSmad2), subepithelial collagen thickness, total lung collagen concentration and AHR (all P < 0.05 vs. respective measurements from saline-treated mice). Daily intranasal delivery of serelaxin significantly diminished AAD-induced epithelial thickening, epithelial pSmad2, subepithelial and total lung collagen content (fibrosis) and AHR (all P < 0.05 vs. vehicle-treated AAD mice).

CONCLUSIONS AND CLINICAL RELEVANCE

Intranasal delivery of serelaxin can effectively reduce airway remodelling and AHR, when administered once daily. Respirable preparations of serelaxin may have therapeutic potential for the prevention and/or reversal of established airway remodelling and AHR in asthma.

Direct cannulation of the infrahepatic vena cava for emergent cardiopulmonary bypass support

Cannulation for cardiopulmonary bypass, although seemingly routine, can pose technical challenges. In patients undergoing repeat sternotomy, for example, peripherally established cardiopulmonary bypass may be necessary to ensure safe entry into the chest; however, establishing bypass in this way can sometimes be complicated by patients' body habitus. We describe a technique for direct cannulation of the infrahepatic abdominal vena cava that was required for emergent cardiopulmonary bypass. The patient was a 62-year-old woman who had presented with severely symptomatic left main coronary stenosis 3 months after elective aortic valve replacement. She had gone into cardiogenic shock as general anesthesia was being induced for repeat sternotomy and myocardial revascularization. Emergent establishment of femorofemoral cardiopulmonary bypass was precluded by difficulties in advancing the femoral venous cannula beyond the pelvic brim. Hence, an emergent celiotomy was performed, and the abdominal vena cava was directly cannulated to establish venous drainage for cardiopulmonary bypass. The rest of the operation was uneventful. Our technique for direct cannulation of the infrahepatic abdominal vena cava may be used in exceptional circumstances. Necessary precautions and potential pitfalls are also presented.

Off-pump coronary artery bypass grafting for spontaneous coronary dissection in a 26-year-old patient two weeks post-partum: a case report and review

Spontaneous coronary artery dissections are an infrequent cause of myocardial infarction and have been reported in late stages of pregnancy and in the puerperium phase. We report a case of a 26-year-old post-partum woman who was diagnosed with a spiral coronary dissection of the left anterior descending artery, with a compromised diagonal branch. She underwent an emergent surgical revascularization without the use of cardiopulmonary bypass. The patient's in-hospital clinical course, prognosis, treatment, and potential etiologies are discussed.

Hemoglobin test result variability and cost analysis of eight different analyzers during open heart surgery

The purpose of this study was to compare the variation in hemoglobin (Hgb) values among various point-of-care (POC) analyzers available on the market. Eight analyzers (Gem 3000, ABL 720, ABL 77, Rapidpoint 405, IL 682, GemOPL, Hb 201+, and manual/centrifugation) were compared with the Hgb values from the Beckman Coulter LH750. A total of 72 patient samples were analyzed on each test instrument. The samples were obtained after intubation, after heparinization, during cardiopulmonary bypass, and after protamine administration. Four of the samples were excluded from the study because of delayed sample analysis. The calculated mean differences of reference test method Hgb (mean +/- SD) for all samples (n = 68) were Gem 3000 = 1.431 +/- 0.396 g/dL; ABL 720 = -0.224 +/- 0.240 g/dL; ABL 77 = 0.341 +/- 0.578 g/dL; Rapidpoint 405 = 0.001 +/- 0.205 g/dL; IL 682 = -0.137 +/- 0.232 g/dL; GemOPL = 0.774 +/- 0.427 g/dL; Hb 201+ = 0.110 +/- 0.524 g/dL; and manual/ centrifugation = 0.547 +/- 0.499 g/dL. Cumulative results indicated that the bias in Hgb values from the Gem 3000, ABL720, ABL 77, IL 682, GemOPL, and the manual method were statistically significant (p < .05), compared with the Coulter LH750. Additionally, only the Rapidpoint 405 and Hb 201+ most closely matched the values from the Coulter LH750 (p > .05). Some of the methodologies have previously been shown to be affected during hemodilution, hypoproteinemia, and/or after blood transfusion. There is variability among methodologies, which can give rise to statistically different Hgb values, and one should consider the "ideal" instrument based on this and many other factors. Based on our results, the rank order of closest approximation to the Coulter LH750 measurement was Rapidpoint 405, Hb 201+, IL 682, ABL 720, ABL 77, manual/centrifugation, GemOPL, and Gem 3000.

Role of paraventricular nucleus in mediating sympathetic outflow in heart failure

A number of neurohumoral processes are activated in heart failure, including an increase in the plasma concentration of norepinephrine. Few studies have been performed to examine the role of the central nervous system in the activation of sympathetic outflow during heart failure (HF). In this paper I review these limited studies, with particular emphasis on examining the role of the paraventricular nucleus (PVN) in the exaggerated sympathetic outflow commonly observed in heart failure. The conclusion is that heart failure is associated with changes in specific areas in the brain and that alterations in the activation of neurons in the PVN are likely related to abnormalities in vasopressin production, blood volume regulation, and sympathoexcitation observed in the heart failure state. Furthermore, neuronal nitric oxide within the PVN that is involved in mediating sympathetic outflow via a GABA mechanism from the PVN may be deficient in inhibiting overall sympathetic outflow leading to the exaggerated sympathetic outflow commonly observed in heart failure.

Pneumococcal HtrA protease mediates inhibition of competence by the CiaRH two-component signaling system

Activation of the CiaRH two-component signaling system prevents the development of competence for genetic transformation in Streptococcus pneumoniae through a previously unknown mechanism. Earlier studies have shown that CiaRH controls the expression of htrA, which we show encodes a surface-expressed serine protease. We found that mutagenesis of the putative catalytic serine of HtrA, while not impacting the competence of a ciaRH+ strain, restored a normal competence profile to a strain having a mutation that constitutively activates the CiaH histidine kinase. This result implies that activity of HtrA is necessary for the CiaRH system to inhibit competence. Consistent with this finding, recombinant HtrA (rHtrA) decreased the competence of pneumococcal cultures. The rHtrA-mediated decline in transformation efficiency could not be corrected with excess competence-stimulating peptide (CSP), suggesting that HtrA does not act through degradation of this signaling molecule. The inhibitory effects of rHtrA and activated CiaH, however, were largely overcome in a strain having constitutive activation of the competence pathway through a mutation in the cytoplasmic domain of the ComD histidine kinase. Although these results suggested that HtrA might act through degradation of the extracellular portion of the ComD receptor, Western immunoblots for ComD did not reveal changes in protein levels attributable to HtrA. We therefore postulate that HtrA may act on an unknown protein target that potentiates the activation of the ComDE system by CSP. These findings suggest a novel regulatory role for pneumococcal HtrA in modulating the activity of a two-component signaling system that controls the development of genetic competence.

Amelioration of depressed cardiopulmonary reflex control of sympathetic nerve activity by short-term exercise training in male rabbits with heart failure

The reflex regulation of sympathetic nerve activity has been demonstrated to be impaired in the chronic heart failure (CHF) state compared with the normal condition (Liu JL, Murakami H, and Zucker IH. Circ Res 82: 496-502, 1998). Exercise training (Ex) appears to be beneficial to patients with CHF and has been shown to reduce sympathetic outflow in this disease state (Hambrecht R, Hilbrich L, Erbs S, Gielen S, Fiehn E, Schoene N, and Schuler G. J Am Coll Cardiol 35: 706-713, 2000). We tested the hypothesis that Ex corrects the reduced cardiopulmonary (CP) reflex response to volume expansion in the CHF state. Normal, normal with Ex, CHF, and CHF with Ex (CHF-Ex) groups (n = 10-21) of male New Zealand White rabbits were studied. CHF was induced by chronic ventricular pacing. Rabbits were instrumented to record left ventricular end-diastolic pressure (LVEDP), left ventricular end-diastolic diameter (LVEDD), and renal sympathetic nerve activity (RSNA). Experiments were carried out with the animals in the conscious state. Volume expansion was performed with 6% dextran in normal saline at a rate of 5 ml/min to approximately 20% of estimated plasma volume without any significant effect on mean arterial pressure being exhibited. The relationships between RSNA and LVEDP and between RSNA and LVEDD were determined by linear regression; the slopes served as an index of CP reflex sensitivity. Normal rabbits exhibited a CP reflex sensitivity of -8.4 +/- 1.5%delta RSNA/mmHg. This value fell to 0.0 +/- 1.3%delta RSNA/mmHg in CHF rabbits (P < 0.001). Ex increased CP reflex sensitivity to -5.0 +/- 0.7%delta RSNA/mmHg in CHF-Ex rabbits (P < 0.05 compared with CHF). A similar trend was seen when related to the change in LVEDD. Furthermore, resting RSNA expressed as a percentage of maximum RSNA in response to cigarette smoke was also normalized by Ex in rabbits with CHF. Ex had no effect on these parameters in normal rabbits. These data confirm an impairment of CP reflex sensitivity and sympathoexcitation in CHF vs. normal animals. Ex substantially restored both CP reflex sensitivity and baseline RSNA in CHF animals. Thus Ex beneficially affects reflex regulation in CHF, thereby lowering resting sympathetic nerve activity.

Proposed role of the paraventricular nucleus in cardiovascular deconditioning

AIM

Cardiovascular deconditioning occurs in individuals exposed to prolonged spaceflight or bedrest and is associated with the development of orthostatic intolerance. Although the precise mechanisms remain to be fully elucidated, astronauts returning from space or bedrest patients returning to normal upright posture present with decreases in plasma volume and alterations in autonomic function. The hindlimb unloaded (HU) rat has been a useful model to study the effects of cardiovascular deconditioning as it mimics many of the changes that occur after spaceflight and bedrest.

RESULTS

Experiments performed in HU rats suggest that cardiovascular deconditioning attenuates baroreflex mediated sympathoexcitation and enhances cardiopulmonary receptor mediated sympathoinhibition. These alterations appear to be due to changes in the central nervous system and may contribute to the pre disposition towards orthostatic intolerance associated with cardiovascular deconditioning. The paraventricular nucleus (PVN) of the hypothalamus is important in basal and reflex control of sympathetic outflow. Recent evidence suggests that nitric oxide (NO) is an important inhibitory neurotransmitter in the PVN and that alterations in nitroxidergic transmission in the PVN may be involved in elevated sympathetic tone in certain disease states.

CONCLUSION

Based on evidence from other laboratories and published and preliminary data from our own laboratories, this review proposes a role for the PVN in cardiovascular deconditioning. In particular, we discuss the hypothesis that increased NO in the PVN contributes to the altered cardiovascular reflexes observed following deconditioning and how these reflexes may be related to the orthostatic intolerance observed after prolonged spaceflight or bedrest.

Modifications to central neural circuitry during heart failure

AIM

During heart failure (HF), excess sodium retention is triggered by increased plasma renin-angiotensin-aldosterone activity and increased basal sympathetic nerve discharge (SND). Enhanced basal SND in the renal nerves plays a role in sodium retention. Therefore, as a hypothetical model for the central sympathetic control pathways that are dysregulated as a consequence of HF, the central neural pathways regulating the sympathetic motor output to the kidney are reviewed in the context of their role during HF.

CONCLUSION

From these findings, a model of the neuroanatomical circuitry that may be affected during HF is constructed.

Paraventricular nucleus of the hypothalamus and elevated sympathetic activity in heart failure: the altered inhibitory mechanisms

AIM

There is a characteristic neurohumoral activation in heart failure (HF). However, few studies have been performed to examine the role of the central nervous system in the activation of sympathetic outflow during HF. In this paper we review some of our studies, with particular emphasis on examining the role of the paraventricular nucleus (PVN) in the exaggerated sympathetic outflow commonly observed in HF.

RESULTS

Our studies have revealed that the inhibitory mechanisms regulating sympathetic outflow are mediated by nitric oxide (NO) and gamma-aminobutyric acid (GABA) within the PVN and are attenuated in HF. These alterations are associated with elevated sympathetic activity. Furthermore, these studies have indicated that the interactions among excitatory (angiotensin II and glutamate) and inhibitory (NO and GABA) neurotransmitters/mediators within the PVN significantly influence sympathetic outflow.

CONCLUSION

Reduced inhibitory actions of NO and/or GABA within the PVN may exaggerate an increase in the actions of excitatory neurotransmitters such as glutamate and angiotensin II within the PVN and this may contribute to the overall sympatho-excitation commonly observed in HF.

NMDA-mediated increase in renal sympathetic nerve discharge within the PVN: role of nitric oxide

The paraventricular nucleus (PVN) of the hypothalamus is an important site of integration in the central nervous system for sympathetic outflow. Both glutamate and nitric oxide (NO) play an important role in the regulation of sympathetic nerve activity. The purpose of the present study was to examine the interaction of NO and glutamate within the PVN in the regulation of renal sympathetic nerve activity in rats. Renal sympathetic nerve discharge (RSND), arterial blood pressure (BP), and heart rate (HR) were measured in response to administration of N-methyl-D-aspartic acid (NMDA) and N(G)-monomethyl-L-arginine (L-NMMA) into the PVN. We found that microinjection of NMDA (25, 50, and 100 pmol) into the PVN increased RSND, BP, and HR in a dose-dependent manner, reaching 53 +/- 9%, 19 +/- 3 mmHg, and 32 +/- 12 beats/min, respectively, at the highest dose. These responses were significantly enhanced by prior microinjection of L-NMMA. On the other hand, inhibition of NO within the PVN by microinjection of L-NMMA also induced increases in RSND, BP, and HR in a dose-dependent manner, reaching 48 +/- 6.5%, 11 +/- 4 mmHg, and 55 +/- 16 beats/min, respectively, at the highest dose. This sympathoexcitatory response was eliminated by prior microinjection of DL-2-amino-5-phosphonovaleric acid, an antagonist of the NMDA receptor. Furthermore, with the use of the push-pull technique, perfusion of glutamate (0.5 micromol) or NMDA (0.1 nmol) into the PVN induced an increase in NO release. In conclusion, our data indicate that NMDA receptors within the PVN mediate an excitatory effect on renal sympathetic nerve activity, arterial BP, and HR. NO in the PVN, which is released by activation of the NMDA receptor, also inhibits NMDA-mediated increases in sympathetic nerve activity. This negative feedback of NO on the glutamate system within the PVN may play an important role in maintaining the overall balance and tone of sympathetic outflow in normal and pathophysiological conditions known to have increased sympathetic tone.

Neural circuitry of the kidney: NO-containing neurons

The neurons synthesizing nitric oxide (NO) that are part of the renal sympathetic pathways were located by double-staining for the neuronal isoform of nitric oxide synthase (nNOS) using immunocytochemistry to identify NO-synthesizing neurons and transneuronal tracing following infection of the left kidney with pseudorabies virus (PRV). Following kidney injection with PRV, the animals survived 4-day post-inoculation prior to sacrifice and tissue processing. PRV-infected neurons that double-stained for nNOS were found in the paraventricular hypothalamic nucleus (PVN), the raphe obscurus nucleus (ROb), the ventromedial medulla (VMM), the rostral ventrolateral medulla (rVLM) and the A5 cell group. In the thoracolumbar spinal cord, nNOS neurons co-localized with PRV-infected cells in the dorsal horn in laminae I, III-V ipsilateral to the injected kidney and in lamina X, the intermediolateral cell column, the lateral funiculus, the intercalated nucleus and the central autonomic area. We conclude that NO synthesizing cells may significantly affect renal autonomic pathways in the rat by interacting with the renal sensory and sympathomotor circuitry at multiple sites.

Tetrahydrobiopterin, a cofactor for NOS, improves endothelial dysfunction during chronic alcohol consumption

We sought to investigate mechanisms that may account for impaired nitric oxide synthase (NOS)-dependent dilatation of cerebral arterioles during alcohol consumption. Our goals were to examine 1) the effect of exogenous application of a cofactor for NOS, i.e., tetrahydrobiopterin (BH4) on the reactivity of pial arterioles during alcohol consumption; and 2) endothelial NOS (eNOS) protein in nonalcohol-fed and alcohol-fed rats. Sprague-Dawley rats were fed liquid diets with or without alcohol for 2-3 mo. We measured in vivo diameter of pial arterioles in response to NOS-dependent agonists (ACh and ADP) and a NOS-independent agonist (nitroglycerin) before and during application of BH4. Blood vessels were then harvested for Western blot analysis of eNOS protein. In nonalcohol-fed rats, ACh and ADP produced vasodilatation, which was impaired in alcohol-fed rats. Vasodilatation to nitroglycerin was similar in both groups of rats. Application of BH4 did not alter vasodilatation in nonalcohol-fed rats but improved impaired vasodilatation in alcohol-fed rats. Also, eNOS protein in cerebral cortex microvessels, the basilar artery, and aorta was not different between nonalcohol-fed and alcohol-fed rats. Thus impaired NOS-dependent vasodilatation during alcohol consumption does not appear to be related to an alteration in eNOS protein but may be related to a deficiency and/or alteration in the utilization of BH4.

Role of nitric oxide in central sympathetic outflow

The gaseous molecule nitric oxide (NO) plays an important role in cardiovascular homeostasis. It plays this role by its action on both the central and peripheral autonomic nervous systems. In this review, the central role of NO in the regulation of sympathetic outflow and subsequent cardiovascular control is examined. After a brief introduction concerning the location of NO synthase (NOS) containing neurons in the central nervous system (CNS), studies that demonstrate the central effect of NO by systemic administration of NO modulators will be presented. The central effects of NO as assessed by intracerebroventricular, intracisternal, or direct injection within the specific central areas is also discussed. Our studies demonstrating specific medullary and hypothalamic sites involved in sympathetic outflow are summarized. The review will be concluded with a discussion of the role of central NO mechanisms in the altered sympathetic outflow in disease states such as hypertension and heart failure.

Paraventricular nucleus bicuculline alters frequency components of sympathetic nerve discharge bursts

Autospectral and coherence analyses were used to determine the effect of paraventricular nucleus (PVN) GABA(A) receptor antagonism [microinfusion or microinjections of bicuculline methiodide (BMI) 100 pmoles] on sympathetic nerve discharge (SND) frequency components (bursting pattern and relationships between discharges in regionally selective nerves) in alpha-chloralose-anesthetized rats. SND was recorded from the renal, splenic, and lumbar nerves. The following observations were made. First, PVN BMI microinjections, but not PVN saline or cortical BMI microinjections, transformed the cardiac-related SND bursting pattern in baroreceptor-innervated rats to one characterized by the presence of low-frequency bursts not synchronized to the cardiac cycle or phrenic nerve discharge bursts. Second, SND pattern changes were similar in the renal, splenic, and lumbar nerves, and peak coherence values relating low-frequency bursts in sympathetic nerve pairs (renal-splenic, renal-lumbar, and splenic-lumbar) were significantly increased from preinjection control after PVN BMI microinjection. Third, PVN BMI microinjections significantly increased the coupling between low-frequency SND bursts in baroreceptor-denervated rats. Finally, PVN BMI-induced changes in the SND bursting pattern were not observed after PVN pretreatment with muscimol (GABA agonist, 1 nmole). We conclude that PVN GABA(A) receptor antagonism profoundly alters the frequency components in sympathetic nerves.

Blunted nitric oxide-mediated inhibition of renal nerve discharge within PVN of rats with heart failure

We have demonstrated a decreased neuronal nitric oxide (NO) synthase (nNOS) message in the hypothalamus of rats with heart failure (HF). Subsequently, we have demonstrated that NADPH diaphorase (a commonly used marker for nNOS activity) positive neurons are decreased in paraventricular nucleus (PVN) of rats with coronary artery ligation model of HF. The goal of the present study was to examine the influence of endogenous NO within the PVN on renal sympathetic nerve discharge (RSND) during HF. In alpha-chloralose- and urethane-anesthetized rats, an inhibitor of NO synthase, N(G)-monomethyl-L-arginine (L-NMMA) microinjected into the PVN (50, 100, and 200 pmol in 50-200 nl) produced a dose-dependent increase in RSND, blood pressure, and heart rate in control and HF rats. These responses were attenuated in rats with HF compared with control rats. On the other hand, the NO agonist, sodium nitroprusside, microinjected in PVN produced a dose-dependent decrease in RSND and blood pressure in control and HF rats. These responses were less in rats with HF compared with control rats. These data suggest that the endogenous NO-mediated effect within the PVN of HF rats is less potent in suppressing RSND compared with control rats. These data support the conclusion that the NO system within the PVN involved in controlling autonomic outflow is altered during HF and may contribute to the elevated levels of renal sympathoexcitation commonly observed in HF.

Renal interstitial hydrostatic pressure and sodium excretion during acute volume expansion in diabetic rats

Experiments were performed to test the hypothesis that the renal interstitial hydrostatic pressure (RIHP) response to acute volume expansion is suppressed in diabetes mellitus. Sprague-Dawley rats received streptozotocin (STZ rats; 65 mg/kg ip) or vehicle (Sham rats). Two weeks later, RIHP and Na(+) excretion responses to acute graded volume expansion with isotonic saline were quantified under Inactin anesthesia (0.1 mg/kg ip). In Sham rats, acute graded volume expansion to 10% body wt produced increases in RIHP (Delta = 12.2 +/- 2.4 mmHg), urine flow (Delta = 54 +/- 8 microliter. min(-1). g(-1)), and Na(+) excretion (Delta = 11.5 +/- 1.9 mueq. min(-1). g(-1)). In STZ rats, these volume expansion-induced responses were significantly blunted (RIHP by 50%, urine flow by 81%, and Na(+) excretion by 76%). Renal decapsulation eliminated the differences between STZ and Sham rats with regard to volume expansion-induced increases in RIHP, urine flow, and Na(+) excretion. Renal denervation normalized the RIHP response to volume expansion and improved the diuretic and natriuretic responses in STZ rats. Moreover, diuretic and natriuretic responses to direct changes in RIHP (induced by renal interstitial volume expansion) were blunted in STZ rats. We conclude that diminished alterations in RIHP, as well as a reduced impact of RIHP on Na(+) excretion, contribute to the impaired diuretic and natriuretic responses to acute volume expansion during the early stage of diabetes.

The regulation of sympathetic outflow in heart failure. The roles of angiotensin II, nitric oxide, and exercise training

Sympatho-excitation is a hallmark of the chronic heart failure (CHF) state. It has long been assumed that this sympatho-excitation is mediated by a reduction in sensory input from cardiopulmonary and arterial baroreceptors. However, recent data suggest that these reflexes may only be important in the initiation of the sympatho-excitatory state and may not be necessary for the sustained increase in sympathetic nerve activity (SNA) in CHF. Two humoral factors that can influence SNA are nitric oxide (NO) and angiotensin II (AngII). Animals with CHF exhibit a downregulation in central gene expression for the neuronal isoform of nitric oxide synthase (nNOS). In addition, blockade of AngII receptors in combination with NO donation reduces SNA in animals with CHF, while NO donation alone has no effect on SNA. Chronic exercise training (EX) reduces both plasma AngII and SNA in rabbits with CHF while improving baroreflex function. Blockade of AT1 receptors enhances baroreflex function in non-EX CHF rabbits, but has little effect in EX CHF rabbits. These data suggest that the sympatho-excitatory state that is typical of CHF is, in part, due to changes in AngII and NO. Depressed baroreflex function and the elevated SNA can be improved by EX in animals with CHF.

Inhibition of K+ currents by homocysteine in rat ventricular myocytes

INTRODUCTION

Clinical evidence suggests that increased blood levels of homocysteine may be an independent risk factor for the development of cardiovascular disease, but the functional effects of this sulfhydryl amino acid on the myocardium are poorly understood. The present study was conducted to determine the direct effects of homocysteine on the electrophysiologic properties of the heart.

METHODS AND RESULTS

Whole-cell voltage-clamp recordings were made in ventricular myocytes isolated from normal rat hearts to analyze the Ca2+-independent, transient outward K+ current (I(to)), a major repolarizing current in these cells. Maximum I(to) density (measured at +60 mV) was decreased approximately 47% from baseline in the presence of 500 microM homocysteine (P < 0.05), but the amount of block varied in a frequency- and voltage-dependent manner. Decreased I(to) density was not accompanied by significant changes in voltage- or time-dependent properties of the current, nor was it affected by pretreating myocytes with the protein kinase inhibitor staurosporine. Because a portion of total extracellular homocysteine is oxidized, we examined the response to homocystine, the oxidized form of homocysteine. In myocytes superfused with 500 microM homocystine, maximum I(to) density was decreased by approximately 40% from baseline (P < 0.05). In contrast, the thiolactone form of homocysteine did not alter I(to) amplitude.

CONCLUSION

These data suggest that homocysteine and its oxidized form homocystine acutely inhibit I(to) channels in ventricular myocytes by mechanisms involving the free thiol or disulfide moieties of these compounds. High homocysteine or homocystine levels may contribute to abnormal repolarization and arrhythmogenic conditions in the intact heart.

Chronic exercise reduces sympathetic nerve activity in rabbits with pacing-induced heart failure: A role for angiotensin II

BACKGROUND

Chronic exercise (EX) improves the quality of life and increases the survival of patients with chronic heart failure (CHF). Because sympathetic nerve activity is elevated in the CHF state, it is possible that EX is beneficial in this disease due to a decrease in sympathetic outflow.

METHODS AND RESULTS

We evaluated arterial baroreflex function and resting renal sympathetic nerve activity (RSNA) in EX normal and CHF rabbits before and after angiotensin II type 1 (AT(1)) receptor blockade. Four groups of rabbits were studied: a normal non-EX group, a normal EX group, a CHF non-EX group, and a CHF EX group. EX lowered resting RSNA in rabbits with CHF but not in normal rabbits. In addition, EX increased arterial baroreflex sensitivity in the CHF group (heart rate slope: CHF 1. 7+/-0.3 bpm/mm Hg, EX CHF 4.9+/-0.3 bpm/mm Hg; P:<0.01; RSNA slope: CHF 2.2+/-0.2%max/mm Hg, EX CHF 5.7+/-0.4%max/mm Hg; P:<0.01. AT(1) receptor blockade enhanced baroreflex sensitivity in the non-EX CHF rabbits but had no effect in EX CHF rabbits. Concomitant with this effect, EX lowered the elevated plasma angiotensin II concentration in the CHF group. A significant positive correlation was observed between sympathetic nerve activity and plasma angiotensin II.

CONCLUSIONS

These data strongly suggest that EX reduces the sympathoexcitatory state in the setting of CHF. Enhanced arterial baroreflex sensitivity may contribute to this reduction. In addition, EX lowers plasma angiotensin II concentration in CHF. These data further suggest that the lowering of angiotensin II may contribute to the decrease in sympathetic nerve activity after EX in the CHF state.

Neuronal expression of Fos protein in the hypothalamus of rats with heart failure

We sought to identify the areas that have altered neuronal activity within the hypothalamus of rats with heart failure (HF) by mapping neuronal staining of c-Fos protein (Fos) 6-8 weeks following coronary artery ligation (HF group; n=17) or sham surgery (sham-operated control group, n=15). Fos-like immunoreactivity was observed in the paraventricular nucleus (PVN), supraoptic nucleus (SON), median preoptic nucleus (MnPO), anterior hypothalamus (AH) and posterior hypothalamus (PH) using a standard ABC immunocytochemical protocol. The rats in the HF group displayed infarcts averaging 34+/-2% of the outer circumference and 41+/-1% of the inner circumference of the left ventricular wall. Sham-operated control rats had no observable damage to the myocardium. Rats with chronic heart failure (n=5) but no manipulation (no surgery) had a similar number of Fos-staining cells in PVN SON, MnPO, AH and PH compared to sham-operated rats. Acute surgery for isolation of vagus nerves and anesthesia for 90 min increased the number of Fos positive cells in PVN, SON and MnPO of both sham-operated rats and rats with HF. Furthermore, rats with heart failure (n=5) had significantly higher number of Fos-staining cells in PVN (four times), SON (4.5 times) and MnPO (1.5 times) compared to sham-operated rats after acute surgery for isolation of the vagus. The number of Fos-staining cells remained unaltered in AH and PH in both groups of rats. However, in a third series of experiments vagotomy reduced the number of Fos-staining cells in the PVN, SON or MnPO of rats with HF (n=5) to those observed in sham-operated vagotomized rats. This study shows that: (1) there is augmented neuronal activity as indicated by increased number of Fos staining neurons in the PVN, SON and MnPO due to acute surgical stress in rats with HF, and (2) vagal afferents are responsible for the increased neuronal activity in PVN, SON and MnPO of rats with HF during acute surgical stress. These data support the conclusion that vasopressin producing neurons and autonomic areas within the hypothalamus influenced by vagal afferents are activated during HF and are sensitive to 'acute surgical stress' and may contribute to the elevated levels of vasopressin and sympatho-excitation commonly observed in heart failure.

Activation of renal afferent pathways following furosemide treatment. I. Effects Of survival time and renal denervation

Three experiments were performed to determine whether renal afferent pathways were activated by the diuretic drug, furosemide. It was hypothesized that activated neurons of the renal afferent pathway would express the protein product Fos of the c-fos immediate early gene and be identified by immunocytochemical staining for Fos in the cell nucleus. In the first two experiments, rats were injected with either furosemide (5 mg) or vehicle solution (sterile isotonic saline) and sacrificed either 1.75 h (short-survival experiment) or 3.5 h (long-survival experiment) after injection. In both experiments, the furosemide-treated rats had significantly more Fos-positive cell nuclei than vehicle-treated rats in the subfornical organ (SFO), organum vasculosum lamina terminalis (OVLT), supraoptic nuclei (SON), and magnocellular region of the paraventricular nuclei (PVN) - areas previously shown to be activated by hypovolemia or peripheral angiotensin. In the short-survival experiment, the furosemide-treated rats had more Fos-positive cell nuclei in the nucleus of the solitary tract (NTS) and in the dorsal horn of the spinal cord at spinal levels T(11), T(12), and T(13). In contrast, furosemide treatment did not produce more Fos-positive cell nuclei in the NTS and dorsal horn of the spinal cord in the long-survival experiment. These results suggest that the activation of the SFO, OVLT, SON and PVN may be via a different mechanism than that of NTS or spinal cord dorsal horn. Based upon our previous work, we hypothesized that the NTS and spinal cord dorsal horn labeling was due to activation of sympathetic afferents originating in the kidney and labeling in forebrain structures was due to stimulation by angiotensin generated by renal renin release. To test this hypothesis, a third experiment was devised that was identical to the short-survival experiment, except that all rats had bilateral renal denervation surgery 1 week previously. In this experiment, furosemide administration increased the number of Fos-positive cells in the SFO, OVLT, SON and PVN, but not in the caudal thoracic spinal cord or NTS. These results together with the results of first two experiments lend support to our hypothesis that furosemide-induced neuronal activation in the thoracic spinal cord and NTS is due to activation of second- and/or third-order neurons of a renal sympathetic afferent pathway. Furosemide-induced activation in the SFO, OVLT, SON and PVN does not depend on renal innervation. It is hypothesized that activation in these forebrain regions depends on the action of angiotensin II that is generated after furosemide treatment. Our results indicate that both a hormonal pathway and a renal sympathetic afferent pathway conduct information from the kidney to the central nervous system (CNS) after furosemide treatment.

Norepinephrine turnover in peripheral tissues of rats with heart failure

Experiments were performed to determine if there is regional heterogeneity in sympathetic neural activation of peripheral tissues in rats with chronic heart failure (HF; 6-8 wk after coronary artery ligation). Norepinephrine (NE) turnover, an index of sympathetic activation, was determined on the basis of the decline in tissue NE levels that occurs during the 8-h after tyrosine hydroxylase inhibition (alpha-methyl-DL-p-tyrosine, 300 mg/kg ip at 4-h intervals). Compared with sham-operated rats, NE turnover was increased in the cardiac left ventricle, skeletal muscle, duodenum, and kidney of rats with HF, but was unaltered in liver and spleen. The increased renal NE turnover in HF was largely a reflection of increased turnover in the cortex, with no change evident in the medulla. Blockade of sympathetic ganglionic traffic (hexamethonium, 2 mg/kg sc at 2-h intervals) eliminated the tissue-specific effects of HF on tissue NE levels measured 8-h after tyrosine hydroxylase inhibition. These data support the contention that chronic HF evokes a central nervous system-mediated increase in basal sympathetic tone that exhibits regional heterogeneity (both between and within organs), a phenomenon that likely contributes to the functional consequences of this pathophysiological state.

Chronic endothelin blockade in dogs with pacing-induced heart failure: possible modulation of sympathoexcitation

BACKGROUND

Endothelin-1 (ET-1) is a potent vasoconstrictor peptide elaborated by many cell types. Plasma ET-1 levels are significantly augmented in patients and experimental animals with heart failure. Enhanced levels of ET-1 may contribute to myocardial depression and alterations in sympathetic nerve activity in the setting of chronic heart failure. The effects of chronic blockade of endothelin A (ET(A)) receptors on the development and severity of experimental heart failure and sympathoexcitation were evaluated in these experiments using the specific ET(A) antagonist, PD156707.

METHODS AND RESULTS

Four groups of conscious, chronically instrumented mongrel dogs were administered either PD156707 (750 mg orally thrice daily) or a placebo starting 1 day before ventricular pacing or a sham (nonpaced) period. Before pacing or the sham period, baseline hemodynamic and plasma norepinephrine (NE) measurements were made. Hemodynamic and NE measurements were made every 3 to 4 days for the next 28 days. All parameters were relatively stable in nonpaced dogs administered placebo. Paced placebo dogs showed classic hemodynamic and sympathoexcitatory changes indicative of heart failure. Nonpaced dogs administered PD156707 showed a significant decrease in mean arterial pressure and total peripheral resistance beginning 3 days after drug administration. Myocardial function was not affected by PD156707 in nonpaced dogs. In paced dogs, PD156707 also reduced arterial pressure and peripheral resistance. Changes in myocardial function were small and insignificant. Paced dogs administered PD156707 showed an approximately 50% lower increase in plasma NE level from days 10 to 24 compared with paced dogs administered placebo (941.8 +/- 122.8 vs 501.1 +/- 92.6 pg/mL at 17 days; P < .01).

CONCLUSIONS

These data suggest that ET-1 contributes to the maintenance of arterial pressure in both sham dogs and dogs paced into heart failure. ET-1 does not appear to have a potent effect on inotropic state, but the data strongly suggest that ET-1 may contribute to the progressive deterioration of circulatory function in heart failure by mediating sympathoexcitation and enhancing plasma NE concentration.

Suppressed impact of nitric oxide on renal arteriolar function in rats with chronic heart failure

We performed experiments to test the hypothesis that experimental heart failure (HF) is associated with altered nitric oxide (NO)-dependent influences on the renal microvasculature, including diminished modulation of constrictor responses to ANG II. Eight to ten weeks after inducing HF in rats by coronary artery ligation, we administered enalaprilat to suppress ANG II synthesis and studied renal arteriolar function using the in vitro blood-perfused juxtamedullary nephron technique. In kidneys from sham-operated rats, NO synthase inhibition [100 microM Nomega-nitro-L-arginine (L-NNA)] reduced afferent arteriolar diameter by 4.1 +/- 0.6 microm and enhanced ANG II responsiveness (10 nM ANG II decreased afferent diameter by 10.1 +/- 1.4 micrometer before and 12.8 +/- 1.6 micrometer during L-NNA treatment; P < 0.05). In kidneys from HF rats, L-NNA did not alter afferent arteriolar baseline diameter or ANG II responsiveness (10 nM ANG II decreased diameter by 12.5 +/- 1.5 micrometer before and 12.5 +/- 2.3 micrometer during L-NNA). The effects of L-NNA on efferent arteriolar function were also abated in HF rats. In renal cortex of HF rats, NO synthase activity was decreased by 63% and superoxide dismutase activity was diminished by 39% relative to tissue from sham-operated rats. Urinary nitrate/nitrite excretion was also reduced in HF rats. Thus both diminished synthesis and augmented degradation are likely to contribute to a decreased renal microvascular impact of endogenous NO during chronic HF, the consequences of which include loss of NO-dependent modulation of ANG II-induced vasoconstriction.

Effect of nitric oxide within the paraventricular nucleus on renal sympathetic nerve discharge: role of GABA

Both nitric oxide (NO) and GABA are known to provide inhibitory inputs to the paraventricular nucleus (PVN) of the hypothalamus and are involved in the control of sympathetic outflow. The purpose of the present study was to examine the interaction of NO and GABA in the regulation of renal sympathetic nerve activity in rats. The responses of renal nerve activity, blood pressure, and heart rate to microinjection of sodium nitroprusside (SNP), an NO donor, into the PVN were measured in the presence and absence of blockade of the GABA system (bicuculline; 2 nmol). Microinjection of SNP (50, 100, and 200 nmol) into the PVN elicited significant decreases in renal nerve discharge, arterial blood pressure, and heart rate, reaching -36.4 +/- 9.7%, -11 +/- 5 mmHg, and -34 +/- 14 beats/min, respectively, at the highest dose. These responses were eliminated by blockade of the GABA system. Conversely, microinjection of Nomega-nitro-L-arginine methyl ester (L-NAME; 50, 100, and 200 nmol) elicited significant increases in the renal sympathetic nerve discharge, arterial blood pressure, and heart rate, reaching 88.9 +/- 16.6%, 9 +/- 1 mmHg, and 29 +/- 9 beats/min, respectively, at the highest dose. These sympathoexcitatory responses were masked by prior blockade of the GABA system with bicuculline. The sympathoexcitatory effect of L-NAME was also eliminated by activation of the GABA system with muscimol. In conclusion, our data indicate that the inhibitory effect of endogenous NO within the PVN on the renal sympathetic nerve activity is mediated by GABA.

Treatment with dimethylthiourea prevents impaired dilatation of the basilar artery during diabetes mellitus

The goal of this study was to test the hypothesis that the synthesis/release of hydroxyl radical accounts for impaired nitric oxide synthase-dependent dilatation of the basilar artery during diabetes mellitus. We measured the diameter of the basilar artery in vivo in nondiabetic and diabetic rats (streptozotocin, 50-60 mg/kg ip) in response to nitric oxide synthase-dependent agonists (acetylcholine and substance P) and a nitric oxide synthase-independent agonist (nitroglycerin). Reactivity of the basilar artery was measured in untreated nondiabetic and diabetic rats and in nondiabetic and diabetic rats treated with a daily intraperitoneal injection of dimethylthiourea (DMTU; 50 mg/kg). Injection of DMTU was started 48 h after injection of streptozotocin and was continued throughout the diabetic period (3-4 wk). Topical application of acetylcholine (0.1, 1.0, and 10 microM) and substance P (0.1 and 1.0 microM) produced similar dilatation of the basilar artery in untreated and DMTU-treated nondiabetic rats. In untreated diabetic rats, the magnitude of vasodilation produced by acetylcholine and substance P was significantly less than in untreated nondiabetic rats. However, in DMTU-treated diabetic rats, dilatation of the basilar artery in response to acetylcholine and substance P was similar to that observed in nondiabetic rats. Dilatation of the basilar artery in response to nitroglycerin was similar in untreated and DMTU-treated nondiabetic and diabetic rats. These findings suggest that impaired nitric oxide synthase-dependent dilatation of the basilar artery during diabetes mellitus may be related to the synthesis/release of hydroxyl radical.

Altered number of diaphorase (NOS) positive neurons in the hypothalamus of rats with heart failure

Recently, we have demonstrated a decreased neuronal isoform of nitric oxide synthase (nNOS) message in the hypothalamus of rats with heart failure (HF). The purpose of this study was to determine the changes in NADPH-diaphorase (a commonly used marker for neuronal NOS activity) positive neurons in specific hypothalamic sites of rats with HF. After a standard histochemical protocol, NOS positive neurons were measured in paraventricular nucleus (PVN), supraoptic nucleus (SON), median preoptic area (MePO), subfornical organ (SFO), organum vasculosum of the lamina terminalis (OVLT) and lateral hypothalamus (LH) of rats with coronary artery ligation (HF group; n=8) and sham-operated control rats (n=9). A total of 4 months after coronary ligation, the rats in the HF group displayed infarcts greater than at least 35% of the left ventricular wall (n = 8). Sham-operated rats had no observable damage to the myocardium. Rats with HF had a significantly lower number of NOS positive cells in the PVN (36% less) compared to sham rats. The number of NOS positive cells remained unaltered in the SON, MePO and LH in rats with HF. Conversely there was an increased number of NOS positive cells in the SFO (42% greater) and OVLT (100% greater). These data support the conclusion that the NO system within the hypothalamus involved in controlling autonomic outflow is altered during HF and may contribute to the elevated levels of vasopressin and sympatho-excitation commonly observed in HF.

Altered K+ current of ventricular myocytes in rats with chronic myocardial infarction

The aim of the present study was to define the cellular mechanisms underlying changes in K+ channel function in the failing heart after myocardial infarction. Rats with left coronary artery ligation were prepared and allowed to recover for 16 wk before study. Animals with chronic infarction exhibited marked cardiac hypertrophy and signs of heart failure, as indicated by a nearly twofold increase in heart weight- and lung weight-to-body weight ratios, respectively, compared with time-matched controls. Cardiac hypertrophy was also evident by a 49% increase in whole cell capacitance of isolated left ventricular myocytes (P < 0.05). Voltage-clamp experiments revealed that the maximum density of the Ca(2+)-independent, transient outward current (I.t.o.), measured at +60 mV, was 42% less in myocytes from infarcted hearts than in myocytes from control hearts (P < 0.05), whereas the inward rectifier current (IK1) density was not different between groups. The reduced Ito density in the infarcted group was reversed, however, in 4-5 h by treatment with exogenous dichloroacetate or pyruvate, both activators of pyruvate dehydrogenase. Moreover, control myocytes incubated for 6 h in the presence of an inhibitor of pyruvate dehydrogenase, 3-bromopyruvate, exhibited a concentration-dependent decrease in Ito density compared with untreated cells. The present data demonstrate that Ito density is reversibly decreased in surviving myocytes from infarcted hearts and suggest that mechanisms related to glucose metabolism via pyruvate dehydrogenase may be involved. These postinfarction changes in myocyte Ito channel function may relate to impaired contractility and arrhythmogenesis, which are characteristic of the intact, failing heart.

Nitric oxide within the paraventricular nucleus mediates changes in renal sympathetic nerve activity

The paraventricular nucleus (PVN) of the hypothalamus is known to be involved in the control of sympathetic outflow. The goal of the present study was to examine the role of nitric oxide within the PVN in the regulation of renal sympathetic nerve activity. Renal sympathetic nerve discharge (RSND), arterial blood pressure, and heart rate in response to the microinjection of nitric oxide synthase inhibitor NG-monomethyl-L-arginine (L-NMMA; 50, 100, and 200 pmol) into the PVN were measured in male Sprague-Dawley rats. Microinjection of L-NMMA elicited an increase in RSND, arterial blood pressure, and heart rate. Administration of NG-monomethyl-D-arginine (D-NMMA, 50-200 pmol) into the PVN did not change RSND, arterial pressure, or heart rate. Similarly, microinjection of another nitric oxide inhibitor NG-nitro-L-arginine methyl ester (L-NAME; 100 nmol) also elicited an increase in RSND, arterial blood pressure, and heart rate. L-Arginine (100 nmol) reversed the effects of L-NAME in the PVN. Furthermore, microinjection of sodium nitroprusside (SNP; 50, 100, and 200 nmol) into the PVN elicited a significant decrease in RSND, arterial blood pressure, and heart rate. These effects of L-NMMA, L-NAME, and SNP on RSND and arterial blood pressure were not mediated by their vasoactive action because microinjection of phenylephrine and hydralazine did not elicit similar respective changes. In conclusion, our data indicate that endogenous nitric oxide within the PVN regulates sympathetic outflow via some inhibitory mechanisms. Altered nitric oxide mechanisms within the PVN may contribute to elevated sympathetic nerve activity observed during various diseases states such as heart failure and hypertension.

Neural regulation in experimental heart failure

The hallmarks of the chronic heart failure state are alterations in autonomic reflexes, neurohumoral drive and fluid balance. The available evidence suggests that several factors contribute to these alterations. These may include peripheral as well as central nervous system abnormalities. However, recent evidence from animals with experimental heart failure suggests that alterations in central neural sites involved in regulating sympathetic outflow may be important in the alterations in autonomic reflexes, neurohumoral drive and fluid balance commonly observed in heart failure. Many of these central mechanisms have not been extensively studied; a comprehensive understanding of these mechanisms will enhance our ability to treat the heart failure condition and its cardiovascular complications.

Effect of L-arginine on reactivity of hamster cheek pouch arterioles during diabetes mellitus

The goal of this study was to determine whether exogenous application of L-arginine could restore impaired agonist-induced increases in arteriolar diameter during diabetes mellitus. We used intravital microscopy to examine reactivity of cheek pouch arterioles (50 microns in diameter) in nondiabetic and diabetic (2 weeks after injection of streptozotocin) hamsters in response to histamine and substance P. In nondiabetic hamsters histamine (1.0 and 5.0 microM) dilated cheek pouch arterioles by 15 +/- 1 and 22 +/- 1%, respectively, and substance P (50 and 100 nM) dilated arterioles by 14 +/- 3 and 21 +/- 4%, respectively. In addition, dilatation of arterioles in response to histamine and substance P in nondiabetic hamsters was abolished by application of an enzymatic inhibitor of nitric oxide synthase (L-NMMA). In contrast, histamine- and substance P-induced increases in arteriolar diameter were markedly reduced in diabetic hamsters. Histamine (1.0 and 5.0 microM) dilated arterioles by only 5 +/- 1 and 4 +/- 2%, respectively, and substance P (50 and 100 nM) dilated arterioles by only 6 +/- 2 and 5 +/- 3%, respectively (p < 0.05 vs. nondiabetic hamsters). Nitroglycerin produced similar vasodilatation in nondiabetic and diabetic hamsters. Next, we examined whether exogenous application of L-arginine (100 microM) could restore impaired histamine- and substance P-induced increases in arteriolar diameter in diabetic hamsters. We found that L-arginine did not restore altered nitric oxide synthase-dependent vasodilatation in diabetic hamsters. These findings suggest that short-term diabetes mellitus alters agonist-induced increases in arteriolar diameter. In addition, the mechanism of altered arteriolar reactivity during diabetes mellitus does not appear to be related to an impaired availability of L-arginine.

Effect of nicotine on endothelium-dependent arteriolar dilatation in vivo

Smoking is a primary risk factor in coronary and peripheral vascular disease. However, the precise component of cigarette smoke that contributes to the pathogenesis of vascular disease remains unclear. The goal of this study was to determine the effect of nicotine on endothelium-dependent dilatation of peripheral resistance arterioles in vivo. We measured the diameter of resistance arterioles (approximately 50 microns in diameter) contained within the microcirculation of the hamster cheek pouch in response to endothelium-dependent (acetylcholine and ADP) and -independent (nitroglycerin) agonists before and after an intravenous infusion of vehicle or two concentrations of nicotine. Acetylcholine, ADP, and nitroglycerin produced a dose-related dilatation of the cheek pouch arterioles under control conditions. Endothelium-dependent, but not -independent, dilatation of arterioles was modestly impaired by an infusion of a low concentration of nicotine (1.0 microgram.kg-1.min-1). Infusion of a higher concentration of nicotine (2 micrograms.kg-1.min-1), which increased the plasma level of nicotine to 14 +/- 1.6 ng/ml, produced a profound selective impairment in endothelium-dependent vasodilatation. We suggest that elevations in plasma nicotine may contribute to the pathogenesis of the peripheral vascular disease observed in smokers.

Increased renal interstitial hydrostatic pressure causes c-fos expression in the rat's spinal cord dorsal horn

To describe a sympathetic afferent circuit, interstitial hydrostatic pressure in the left kidney was increased in anesthetized rats for 1.5 h to activate renal mechanoreceptor afferents. Following renal afferent stimulation, the number of immunocytochemically stained cells for the immediate early gene c-fos was increased within the dorsal horn of the spinal cord. Relative to the surgical control procedure, increasing renal interstitial hydrostatic pressure produced more immunocytochemically stained cells per tissue section in laminae I and II of the dorsal horn both ipsilateral and contralateral to the stimulated kidney in the three most caudal thoracic spinal segments. Further, the number of c-fos immunocytochemically stained cells per section in the dorsal horn ipsilateral to the stimulated kidney was 28% greater than the number of stained cells contralateral to it. The staining patterns in the dorsal horns of stimulated and control animals were similar with most labeled cells in laminae I and II. These results indicate that (1) c-fos immunocytochemical staining may be useful for tracing specific sympathetic afferent pathways, (2) sensory pathways affected by increased renal interstitial hydrostatic pressure include spinal neurons located at lower thoracic levels, and (3) some of this sympathetic afferent pathway is located contralateral to the stimulated kidney. Neurons in the contralateral dorsal horn activated by renal stimulation may mediate renorenal reflexes.

Volume reflex in diabetes

After examining various components of the volume reflex in different models of diabetic rats, it is clear that the neural component of the volume reflex is altered in the early stage of diabetes. Nevertheless, the mechanisms involved in the neural component need to be examined further in diabetes. In terms of the humoral component of the effector limb of the volume reflex, the actions of ANF within the kidney appear to contribute to the altered volume reflex in diabetes. Results of our preliminary studies suggest that intrarenal factors may also contribute to the blunted renal excretory responses to acute VE in early diabetes. Finally, the present review has outlined the major abnormalities in the volume reflex in diabetes and the gaps in our knowledge of the various components of the volume reflex in diabetes.

Renal response to volume expansion in streptozotocin-induced diabetic rats: influence of calcium channel blockade

The renal response to volume expansion (VE) has been shown to be impaired in streptozotocin (STZ)-induced diabetes. This may contribute to the abnormal maintenance of fluid balance in diabetics. Since calcium channel blockade (CaCb) has been shown to improve renal hemodynamic and tubular functions, the present studies were designed to examine the ability of CaCb to enhance the response of kidneys from diabetic rats to a volume load. Rats were made diabetic by a single injection of STZ (65 mg i.p.), while the control rats received only a vehicle injection. Nisoldipine, a CaCb agent was given to half of the diabetic rats in a dose of 0.015 microgram/kg per min during the acute experiment. The left kidney was denervated in each rat while the right kidney remained innervated. Glomerular filtration rate (GFR) was elevated during VE in all of the rats except in the denervated kidneys of diabetic rats. Nisoldipine improved GFR in most cases. Urine flow increased markedly during VE. This response was enhanced by denervation but depressed in the diabetic rats. Nisoldipine improved the defective volume reflex in primarily the denervated kidneys. Changes in net urinary excretion of water and sodium during VE were significantly lower in the diabetic rats than in the control group. In the nisoldipine treated diabetic rats the VE induced changes in water and sodium excretion returned toward normal in the denervated, but not in the innervated kidneys. The data are consistent with a blunted volume reflex in the diabetic rats that may be improved by CaCb. Impaired sympatho-inhibition in diabetic rats appears to oppose the effects of VE and nisoldipine treatment. CaCb may contribute to the volume reflex by enhanced filtration as well as by reduced tubular reabsorption.

Peripheral noradrenergic turnover in streptozotocin-induced diabetic rats

Our goal was to determine whether basal sympathetic tone to the kidney and various peripheral tissues is altered in conscious diabetic rats. Norepinephrine (NE) turnover was determined by measuring the decline in tissue NE concentration ([NE]) at 4 and 8 h after administering alpha-methyl-p-tyrosine to animals from each of three groups, diabetic (STZ injected 4 weeks prior to experimentation), diabetic + insulin (STZ injected; insulin injected; 2 U/day per rat for 4 weeks) and control (n = 18-20 per group). Various peripheral tissues (duodenum, left ventricle of the heart, kidney, skeletal muscle, left adrenal gland and liver) were examined. [NE] was significantly increased in the kidney and liver, but decreased in the duodenum of the diabetic compared to the control rats. In contrast to the changes in [NE], the rate constant, which provides an index of sympathetic tone, increased in the duodenum and liver, and a decreased in the adrenal gland. The turnover of NE, which is a composite of [NE] and rate constant, increased in the kidney and liver, and decreased in the adrenal gland of diabetic rats. Chronic treatment of diabetic rats with insulin normalized NE turnover in the liver, but not in the adrenal gland. Diabetic rats treated with insulin exhibited a reduced turnover of NE in the kidneys. These data demonstrate that there are differential changes in the [NE], rate constant, and turnover of NE in diabetic rats. Overall, these data indicate that there is increased noradrenergic activity to the kidney, possibly related to sodium retention, and a differential change in noradrenergic activation to various peripheral tissues in diabetic rats.

Renal sympathetic nerve discharge mediated by the paraventricular nucleus is altered in STZ induced diabetic rats

The purpose of this study was to determine if the renal sympathetic nerve discharge (RSND), mediated by the paraventricular nucleus of the hypothalamus (PVN), is altered in streptozotocin (STZ) induced diabetic rats. Two to three weeks prior to the start of the experiment the diabetic group was treated with a single injection of STZ (65 mg/kg ip) in a 2% solution of cold 0.1 M citrate buffer (pH = 4.5). The control group was injected with the vehicle alone. Bicuculline (BIC) was injected into the PVN in three different doses (0.5, 1.0 & 2.0 nmol) while the RSND was being monitored. BIC is an antagonist of gamma-aminobutyric acid (GABA) which is an inhibitory neurotransmitter that is thought to exert a tonic inhibitory effect on the PVN. Microinjection of BIC produced a significantly lower response of RSND in the diabetic group compared to the control group. Microinjection of BIC produced a 13, 35 and 33% change in RSND in diabetic rats compared to control group in response to 0.5, 1.0, and 2.0 nmol doses, respectively. Mean blood pressure and heart rate were statistically not different between the control and the diabetic groups. However there were tendencies of the blood pressure and heart rate to be blunted upon injection of BIC into PVN in diabetic rats. This study demonstrates that RSND in response to microinjection of BIC in PVN is decreased significantly in anesthetized diabetic rats, indicating that STZ induced diabetic rats have a blunted RSND response to microinjection of BIC. There is also some evidence, although not statistically significant, for a blunted blood pressure and heart rate were diabetics. These findings suggest that there is a reduced endogenous inhibitory influence of GABAergic mechanisms within the PVN involved in regulating renal sympathetic outflow in the diabetic state.