Renal ammonium production--une vue canadienne

The purpose of this review is to examine the factors regulating ammonium production in the kidney and to place these factors in the perspective of acid-base balance. Renal ammonium production and excretion are required to maintain acid-base balance. However, only a portion of renal ammonium production is specifically stimulated by metabolic acidosis. One should examine urinary ammonium excretion at three levels: distribution of ammonium between blood and urine, augmented glutamine metabolism, and an energy constraint due to ATP balance considerations. With respect to the biochemical regulation of acid-base renal ammonium production, an acute stimulation of alpha-ketoglutarate dehydrogenase by a fall in pH seems to be important but this may not be the entire story. In chronic metabolic acidosis augmented glutamine entry into mitochondria (dog) or increased phosphate-dependent glutaminase activity (rat) become critical to support a high flux rate. Metabolic alterations, which diminish the rate of oxidation of alternate fuels, might also be important. The above principles are discussed in the ketoacidosis of fasting, the clinically important situation of high rates of renal ammonium production.     

Distal Renal Tubular Acidosis Due to Primary Hyperparathyroidism

ObjectiveTo present 4 cases of distal renal tubular acidosis (RTA) in patients with primary hyperparathyroidism (PHPT) and discuss their possible etiopathogenetic correlation.MethodsWe diagnosed distal RTA in 4 patients with symptomatic primary PHPT on the basis of the baseline biochemical variables and the results of the ammonium chloride loading test. Complete resolution of distal RTA was documented after surgical cure of PHPT by removal of a parathyroid adenoma.ResultsAll our patients presented with symptomatic bone disease and metabolic myopathy. One patient presented with recurrent renal stones. Inappropriately alkaline fasting urine (pH > 5.5) in association with a normal anion gap metabolic acidosis suggested the diagnosis of distal RTA. All cases were confirmed by an ammonium chloride loading test. Three patients responded to surgical cure of PHPT by normalization of the acid-base status.ConclusionHypercalciuria in PHPT can lead to nephrocalcinosis and renal tubular dysfunction, which manifests as distal RTA. Cure of distal RTA after surgical treatment of PHPT establishes PHPT as the primary cause of distal RTA in these cases. (Endocr Pract. 2008;14: 1133-1136)     

A bout of resistance exercise increases urinary calcium independently of osteoclastic activation in men

Ashizawa, Noriko, Rei Fujimura, Kumpei Tokuyama, andMasashige Suzuki. A bout of resistance exercise increases urinary calcium independently of osteoclastic activation in men.J. Appl. Physiol. 83(4):1159-1163, 1997.Metabolic acidosis increases urinary calciumexcretion in humans as a result of administration of ammonium chloride,an increase in dietary protein intake, and fasting-inducedketoacidosis. An intense bout of exercise, exceeding aerobic capacity, also causes significant decrease in blood pH as aresult of increase in blood lactate concentration. In this study weinvestigated changes in renal calcium handling, plasma parathyroidhormone concentration, and osteoclastic bone resorption after a singlebout of resistance exercise. Ten male subjects completed about of resistance exercise with an intensity of 60% of one repetitionmaximum for the first set and 80% of one repetition maximum for thesecond and third sets. After exercise, blood and urine pH shiftedtoward acidity and urinary calcium excretion increased.Hypercalciuria was observed in the presence of an increased fractionalcalcium excretion and an unchanged filtered load of calcium. Therefore,the observed increase in urinary calcium excretion was due primarily todecrease in renal tubular reabsorption of calcium. Likely causes of theincrease in renal excretion of calcium are metabolic acidosis itselfand decreased parathyroid hormone. When urinary calcium excretionincreased, urinary deoxypyridinoline, a marker of osteoclastic boneresorption, decreased. These results suggest that1) strenuous resistance exerciseincreased urinary calcium excretion by decreasing renal tubular calciumreabsorption, 2) urinary calciumexcretion increased independently of osteoclast activation, and3) the mechanism resulting inpostexercise hypercalciuria might involve non-cell-mediatedphysicochemical bone dissolution.

     

HOMEOSTATIC ADJUSTMENTS AFTER EXERCISE : I. ACID-BASE EQUILIBRIUM OF THE BLOOD

The rate at which displacement and recovery of the acid-base equilibrium of the blood occur in young adult males subjected to short periods of maximal exertion has been determined. Displacement of acid-base equilibrium produced by severe exercise is along the fixed acid path, similar to the path of displacement produced by ingestion of acidifying agents such as ammonium chloride. Maximum displacement of the acid-base equilibrium is not reached until 7 to 10 minutes after the cessation of exercise. By this time over 50 per cent of the displacement in oxygen consumption, respiratory volume, and blood pressure have disappeared. A much greater metabolic acidosis was produced by exercise than could be induced by the oral administration of ammonium chloride. Recovery from the metabolic acidosis produced by exercise was much more rapid (10 times) than was recovery from the acidosis produced by ammonium chloride. After exercise the pH, returned to normal values more rapidly than did the bicarbonate content of the serum.     

Stimulation of ammonium ion excretion in the toad urinary bladder by an extract of human urine.

It is well known that ammonium ion excretion is increased during metabolic acidosis in mammals. The purpose of this study was to determine whether we could isolate from human urine during metabolic acidosis a factor that would stimulate NH+4 and/or H+ excretion in toad urinary bladder. Extracts of urine from six human subjects collected during NH4Cl-induced acidosis were prepared. These extracts were tested for their effect on NH+4 excretion in hemibladders mounted between plastic chambers. The extracts significantly increased NH+4 excretion in the toad urinary bladder. We found no effect on H+ excretion by these extracts. This ammoniuretic activity was not present in the urine when the same individuals were in metabolic alkalosis. We conclude that during metabolic acidosis a humoral factor is present which stimulates the excretion of NH+4. The factor could act as a permease in the bladder cell or as a stimulator of an NH+4 transport system.     

Effect of NH4Cl acidosis on the function of renin-angiotensin-aldosterone system in newborn infants.

The present study was undertaken to assess the influence of acute metabolic acidosis on the activity of renin-angiotensin-aldosterone system and renal function in a group of seven one-week-old neonates with mean birth weight of 2164 g (range: 1300-3750 g) and mean gestational age of 34 weeks (range: 28-40 weeks) undergoing oral NH4Cl load. NH4Cl was given in a dose of 2.8 mEq/kg to evaluate renal acidification. Prior to and following NH4Cl administration blood acid-base parameters, plasma urinary electrolytes, creatinine and aldosterone concentration as well as plasma renin activity, glomerular filtration rate, urine flow rate and net acid secretion were measured. NH4Cl administration significantly depressed blood pH (P < 0.05), total CO2 content (P < 0.01) and base excess (P < 0.01) and resulted in a significant elevation of plasma potassium concentration (P < 0.05). Furthermore, NH4Cl ingestion significantly increased urine flow rate, sodium, chloride and net acid excretion. In response to NH4Cl acidosis no consistent change in plasma renin activity and plasma aldosterone concentration could be detected. There was, however, an about 50% increase in urinary aldosterone excretion from the control value of 4.1 +/- 1.2 micrograms/day to 6.8 +/- 2.3 micrograms/day (P < 0.05) after NH4Cl administration. These data suggest that the responsiveness of neonatal adrenals to stimulation by metabolic acidosis is blunted, acidosis therefore, may play a minor role in the neonatal hyperfunction of renin-angiotensin-aldosterone system.     

Fibrosing Alveolitis Associated with Renal Tubular Acidosis

The discovery of a case of renal tubular acidosis and fibrosing alveolitis led to the investigation of 19 further patients. Abnormal pulmonary function tests were found in a further four patients with overt renal tubular acidosis and in four out of eight patients with “incomplete” renal tubular acidosis. The response to an ammonium chloride test in seven patients with cryptogenic fibrosing alveolitis was normal. Those patients with a defect of both renal acidification and pulmonary gas transfer had concurrent autoimmune diseases such as Sjögren''s syndrome and primary biliary cirrhosis. It is suggested that the renal and pulmonary abnormalities may be part of a systemic disorder capable of affecting many organs. Moreover, hyperglobulinaemia and autoantibodies in these patients further suggests that immunological mechanisms are concerned in the pathogenesis of these abnormalities.     

Renal enzymes during experimental diabetes mellitus in the rat. Role of insulin, carbohydrate metabolism, and ketoacidosis

The activities of various ammoniagenic, gluconeogenic, and glycolytic enzymes were measured in the renal cortex and also in the liver of rats made diabetic with streptozotocin. Five groups of animals were studied: normal, normoglycemic diabetic (insulin therapy), hyperglycemic, ketoacidotic, and ammonium chloride treated rats. Glutaminase I, glutamate dehydrogenase, glutamine synthetase, phosphoenolpyruvate carboxykinase (PEPCK), hexokinase, phosphofructokinase, fructose-1,6-diphosphatase, malate dehydrogenase, malic enzyme, and lactate dehydrogenase were measured. Renal glutaminase I activity rose during ketoacidosis and ammonium chloride acidosis. Glutamate dehydrogenase in the kidney rose only in ammonium chloride treated animals. Glutamine synthetase showed no particular variation. PEPCK rose in diabetic hyperglycemic animals and more so during ketoacidosis and ammonium chloride acidosis. It also rose in the liver of the diabetic animals. Hexokinase activity in the kidney rose in diabetic insulin-treated normoglycemic rats and also during ketoacidosis. The same pattern was observed in the liver of these diabetic rats. Renal and hepatic phosphofructokinase activities were elevated in all groups of experimental animals. Fructose-1,6-diphosphatase and malate dehydrogenase did not vary significantly in the kidney and the liver. Malic enzyme was lower in the kidney and liver of the hyperglycemic diabetic animals and also in the liver of the ketoacidotic rats. Lactate dehydrogenase fell slightly in the liver of diabetic hyperglycemic and NH4Cl acidotic animals. The present study indicates that glutaminase I is associated with the first step of increased renal ammoniagenesis during ketoacidosis. PEPCK activity is influenced both by hyperglycemia and ketoacidosis, acidosis playing an additional role. Insulin appears to prevent renal gluconeogenesis and to favour glycolysis. The latter would seem to remain operative in hyperglycemic and ketoacidotic diabetic animals.     

Urinary tract infections in children. An update.

Urinary tract infection is a common and frequently recurring condition in children. The susceptibility of the host, the presence of urinary tract abnormalities, and the virulence of the urinary pathogens are of primary importance in the development of the infection. Renal parenchymal scarring, hypertension, and renal insufficiency are well-established complications of the infection in children. To reduce the risk of renal damage, diagnosis and treatment must be prompt. The diagnosis demands radiologic evaluation of the urinary tract in all boys, all children younger than 5 years, all patients with voiding dysfunction, and school-aged girls with recurrent infection to identify those patients with vesicoureteral reflux, obstruction, or other urinary tract abnormalities. Both voiding cystourethrography and renal ultrasonography are the initial examinations to use to determine the next appropriate study. Children with vesicoureteral reflux or with recurrent urinary tract infections should receive prophylactic antibiotic therapy and should be observed closely to prevent renal scarring.     

Inhibition of glutamine synthetase in the mouse kidney: a novel mechanism of adaptation to metabolic acidosis

As part of a study on the regulation of renal ammoniagenesis in the mouse kidney, we investigated the effect of chronic metabolic acidosis on glutamine synthesis by isolated mouse renal proximal tubules. The results obtained reveal that, in tubules from control mice, glutamine synthesis occurred at high rates from glutamate and proline and, to a lesser extent, from ornithine, alanine, and aspartate. A 48 h, metabolic acidosis caused a marked inhibition of glutamine synthesis from near-physiological concentrations of both alanine and proline that were avidly metabolized by the tubules; metabolic acidosis also greatly stimulated glutamine utilization and metabolism. These effects were accompanied by a large increase (i) in alanine, proline, and glutamine gluconeogenesis and (ii) in ammonia accumulation from proline and glutamine. In the renal cortex of acidotic mice, the activity of phosphoenolpyruvate carboxykinase increased 4-fold, but that of glutamate dehydrogenase did not change; in contrast with what is known in the rat renal cortex, metabolic acidosis markedly diminished the glutamine synthetase activity and protein level, but not the glutamine synthetase mRNA level in the mouse renal cortex. These results strongly suggest that, in the mouse kidney, glutamine synthetase is an important regulatory component of the availability of the ammonium ions to be excreted for defending systemic acid-base balance. Furthermore, they show that, in rodents, the regulation of renal glutamine synthetase is species-specific.     

Importance of medullary events in ammonium excretion: studies in acute respiratory and acute metabolic acidosis

The renal medulla can play an important role in acid excretion by modulating both hydrogen ion secretion in the medullary collecting duct and the medullary PNH3. The purpose of these experiments was to characterize the intrarenal events associated with ammonium excretion in acute acidosis. Cortical events were monitored in two ways: first, the rates of glutamine extraction and ammoniagenesis were assessed by measuring arteriovenous differences and the rate of renal blood flow; second, the biochemical response of the ammoniagenesis pathway was examined by measuring glutamate and 2-oxoglutarate, key renal cortical metabolites in this pathway. There were no significant differences noted in any of these cortical parameters between acute respiratory and metabolic acidosis. Despite a comparable twofold rise in ammonium excretion in both cases, the urine pH, PNH3, and the urine minus blood PCO2 difference (U-B PCO2) were lower during acute hypercapnia. In these experiments, the urine PCO2 was 34 mmHg (1 mmHg = 133.322 Pa) lower than that of the blood during acute respiratory acidosis while the U-B PCO2 was 5 +/- 3 mmHg in acute metabolic acidosis. Thus there were significant differences in medullary events during these two conditions. Although the urine pH is critical in determining ammonium excretion in certain circumstances, these results suggest that regional variations in the medullary PNH3 can modify this relationship.     

Lactic acidosis and ketoacidosis: biochemical and clinical implications.

A case of lactic acidosis presented the opportunity for review of the association between lactic acidosis and ketoacidosis. The diagnosis of lactic acidosis or the combination of lactic acidosis and ketoacidosis is established clinically by the detection of a metabolic acidosis of the "unmeasured anion gap" type in the absence of significant renal failure, poison intake or a strongly positive clinical test for ketones. Before treatment can be planned the biochemical basis of lactic acidosis and ketoacidosis must be understood -- especially the fact that lactic acidosis is not a single disease entity but has many possible causes. Among important considerations is the relation between the blood concentrations of bicarbonate and organic acid anions. After recovery from metabolic acidosis of the unmeasured anion gap type, metabolic alkalosis is common. Decreased bicarbonate excretion plays an important role in the pathogenesis of the latter and may be the result of potassium or chloride loss, or both. The deficits, if present, should be corrected with appropriate therapy.     

Stimulation of ammonium ion excretion in the toad urinary bladder by an extract of human urine

It is well known that ammonium ion excretion is increased during metabolic acidosis in mammals. The purpose of this study was to determine whether we could isolate from human urine during metabolic acidosis a factor that would stimulate NH₄⁺ and/or H⁺ excretion in toad urinary bladder. Extracts of urine from six human subjects collected during NH₄Cl-induced acidosis were prepared. These extracts were tested for their effect on NH₄⁺ excretion in hemibladders mounted between plastic chambers. The extracts significantly increased NH₄⁺ excretion in the toad urinary bladder. We found no effect on H⁺ excretion by these extracts. This ammoniuretic activity was not present in the urine when the same individuals were in metabolic alkalosis. We conclude that during metabolic acidosis a humoral factor is present which stimulates the excretion of NH₄⁺. The factor could act as a permease in the bladder cell or as a stimulator of an NH₄⁺ transport system.     

MODERN USE OF URINARY ANTISEPTICS

It is not necessary to resort to complete study in most cases of urinary tract infection. However, if the lesion is chronic or recurrent, associated with mixed organisms, complicated by lower tract involvement, accompanied by low total renal function, with or without abnormalities in a kidney-ureter-bladder x-ray film or in an intravenous urogram, then complete retrograde study should be carried out.A Gram stain will substitute for culture in most simple urinary tract infections and a trial of the agent of choice will act as a test of bacterial sensitivity. If the infection persists, however, more adequate bacteriologic studies are required.For good chemotherapeutic practice, it is important to: (1) Withhold the drug until it has been determined that obstruction, stone or other such lesion is not present; (2) watch for side effects and toxicity; and (3) give the best drug in large enough dosage for an adequate period of time.     

Pendrin in the mouse kidney is primarily regulated by Cl- excretion but also by systemic metabolic acidosis

The Cl(-)/anion exchanger pendrin (SLC26A4) is expressed on the apical side of renal non-type A intercalated cells. The abundance of pendrin is reduced during metabolic acidosis induced by oral NH(4)Cl loading. More recently, it has been shown that pendrin expression is increased during conditions associated with decreased urinary Cl(-) excretion and decreased upon Cl(-) loading. Hence, it is unclear if pendrin regulation during NH(4)Cl-induced acidosis is primarily due the Cl(-) load or acidosis. Therefore, we treated mice to increase urinary acidification, induce metabolic acidosis, or provide an oral Cl(-) load and examined the systemic acid-base status, urinary acidification, urinary Cl(-) excretion, and pendrin abundance in the kidney. NaCl or NH(4)Cl increased urinary Cl(-) excretion, whereas (NH(4))(2)SO(4), Na(2)SO(4), and acetazolamide treatments decreased urinary Cl(-) excretion. NH(4)Cl, (NH(4))(2)SO(4), and acetazolamide caused metabolic acidosis and stimulated urinary net acid excretion. Pendrin expression was reduced under NaCl, NH(4)Cl, and (NH(4))(2)SO(4) loading and increased with the other treatments. (NH(4))(2)SO(4) and acetazolamide treatments reduced the relative number of pendrin-expressing cells in the collecting duct. In a second series, animals were kept for 1 and 2 wk on a low-protein (20%) diet or a high-protein (50%) diet. The high-protein diet slightly increased urinary Cl(-) excretion and strongly stimulated net acid excretion but did not alter pendrin expression. Thus, pendrin expression is primarily correlated with urinary Cl(-) excretion but not blood Cl(-). However, metabolic acidosis caused by acetazolamide or (NH(4))(2)SO(4) loading prevented the increase or even reduced pendrin expression despite low urinary Cl(-) excretion, suggesting an independent regulation by acid-base status.     

The regulation of phosphoenolpyruvate carboxykinase (GTP) synthesis in rat kidney cortex. The role of acid-base balance and glucocorticoids.

The effects of metabolic acidosis and of hormones on the activity, synthesis, and degradation of renal cytosolic P-enolpyruvate carboxykinase (GTP) (EC 4.1.1.32) were studied in the rat using isotopic -immunochemical procedures. At normal acid-base balance, the synthesis of the enzyme accounted for between 2 and 3.5% of the synthesis of all soluble protein in the kidney cortex. P-enolpyruvate carboxykinase synthesis was selectively stimulated in acute metabolic acidosis, so that the relative rate of synthesis of the enzyme was increased to 7% 13 hours after oral administration of ammonium chloride. The stimulation of P-enolpyruvate carboxykinase synthesis preceded any increase in the assayable activity of the enzyme. The administration of sodium bicarbonate to acutely acidotic rats returned the rate of enzyme synthesis to normal in 8 hours. The effect of acidosis on both the synthesis and the activity of P-enolpyruvate carboxykinase was prevented by actinomycin D, cordycepin, and cycloheximide. The degradation in vivo of pulse-labeled P-enolpyruvate carboxykinase was not affected by acidosis. Thus, the stimulation of P-enolpyruvate carboxykinase synthesis is the major mechanism for the increase in the level of the enzyme observed in metabolic acidosis. The administration of glucocorticoid triamcinolone resulted in an increase in the relative rate of P-enolpyruvate carboxykinase synthesis and a commensurate increase in the activity of the enzyme in the renal cortex. Both changes were abolished by actinomycin D. Fasting was characterized by a high enzyme activity and a rapid rate of enzyme synthesis in the kidney cortex. This high rate of synthesis was reduced after the administration of sodium bicarbonate, but not after glucose feeding. Moreover, the injection of insulin to diabetic rats did not repress P-enolpyruvate carboxykinase synthesis in the renal cortex. Theophylline plus N-6, 0-2'-dibutyryl adenosine 3':5'-monophosphate stimulated P-enolpyruvate carboxykinase synthesis in the kidney of intact rats. However, the latter effect was probably due to glucocorticoid secretion, since it did not occur in adrenalectomized animals. The administration of parathyroid extracts did not result in the induction of the enzyme. Thus, the hormonal regulation of cytosolic P-enolpyruvate carboxykinase synthesis in the kidney differs markedly from that in the liver.     

Effect of the blood lactate concentration on renal glutamine metabolism in dogs with chronic metabolic acidosis

It appears that glutamine and lactate are the principal substrates for the kidney in dogs with chronic metabolic acidosis. Accordingly, the purpose of this study was to determine if a higher or lower rate of renal lactate extraction would influence the rate of glutamine extraction at a constant rate of renal ATP turnover. The blood lactate concentration was 0.9 +/- 0.01 mM in 15 acidotic dogs. However, eight dogs with chronic metabolic acidosis had a spontaneous blood lactate concentration of 0.5 mM or lower. The kidneys of these dogs extracted considerably less lactate from the arterial blood (19 vs. 62 mumol/100 mL glomerular filtration rate (GFR]. Nevertheless, glutamine, alanine, citrate, and ammonium metabolism were not significantly different in these two groups of dogs. Renal ATP balance in acidotic dogs with a low blood lactate could only be achieved if a substrate other than additional glutamine were oxidized in that segment of the nephron which normally oxidized lactate; presumably a fat-derived substrate and (or) lactate derived from glucose was now the metabolic fuel at these more distal sites. When the blood lactate concentration was greater than 1.9 mM, lactate extraction rose to 219 mumol/100 mL GFR. Glutamine, alanine, citrate, and ammonium metabolism were again unchanged; in this case, ATP balance required substrate flux to products other than carbon dioxide, presumably, gluconeogenesis. It appears that renal ammoniagenesis is a proximal event and is independent of the rate of renal lactate extraction.     

Changes in Renal Tubular and Glomerular Functions and Biological Acid–Base Balance after Soil Replacement in Cd-Polluted Rice Paddies Calculated with a General Linear Mixed Model

Using a general linear mixed model, we conducted a 10-year follow-up investigation of 29 persons requiring observation in the cadmium (Cd)-polluted Kakehashi River basin to determine serial changes in biological parameters after removal of Cd-polluted soil present in rice paddies. In particular, we investigated changes in urinary Cd, urinary total protein, biological acid-base balance based on arterial blood pH, carbon dioxide tension (Pa(CO2)), base excess (BE), serum chloride ion (SCl(-)), and renal glomerular function based on serum creatinine (SCr) and creatinine clearance (C(Cr)). In both sexes, urinary Cd concentrations decreased and total protein concentrations increased with increasing number of years elapsed, with the partial regression coefficients statistically significant in the women. Partial regression coefficients showed positive values for SCl(-), with statistical significance in both sexes. The value for Pa(CO2) was significantly negative in men. Given the serial changes in arterial blood pH, Pa(CO2), BE, SCl(-), it is suggested that the biological acid-base balance will progress to metabolic acidosis with hyperchloremia. Moreover, glomerular dysfunction as indicated by an increase in SCr and a decrease in C(Cr) will continue to progress even after soil replacement. Interventions such as soil replacement appear to be too late to prevent progressive renal failure in Cd-exposed populations.