Enalapril in the treatment of hypertension with renal artery stenosis.

The converting enzyme inhibitor enalapril, in single daily doses of 10-40 mg, was given to 20 hypertensive patients with renal artery stenosis. The blood pressure fall six hours after the first dose of enalapril was significantly related to the pretreatment plasma concentrations of active renin and angiotensin II and to the concurrent fall in angiotensin II. Blood pressure fell further with continued treatment; the long term fall was not significantly related to pretreatment plasma renin or angiotensin II concentrations. At three months, 24 hours after the last dose of enalapril, blood pressure, plasma angiotensin II, and converting enzyme activity remained low and active renin and angiotensin I high; six hours after dosing, angiotensin II had, however, fallen further. The rise in active renin during long term treatment was proportionally greater than the rise in angiotensin I; this probably reflects the fall in renin substrate that occurs with converting enzyme inhibition. Enalapril alone caused reduction in exchangeable sodium, with distinct increases in serum potassium, creatinine, and urea. Enalapril was well tolerated and controlled hypertension effectively long term; only two of the 20 patients required concomitant diuretic treatment.     

Cyclosporin treatment of IgA nephropathy: a short term controlled trial.

Cyclosporin''s known regulatory effects on the immune system suggest that it may be useful in treating patients with IgA nephropathy. A randomised prospective single blind study of 19 patients with IgA nephropathy and proteinuria (greater than 1.5 g/day) was conducted to determine the therapeutic value of cyclosporin. The patients were divided into two groups: nine patients were given oral cyclosporin (5 mg/kg/day) for 12 weeks and 10 patients a placebo. The two groups were comparable in age of presentation, ratio of men to women, plasma creatinine and serum IgA concentrations, creatinine clearance, daily urinary protein excretion, severity of renal histopathological changes, and prevalence of hypertension. A significant reduction of proteinuria and an increase of plasma albumin concentration was observed with treatment with cyclosporin. Nevertheless, a significant rise of plasma creatinine concentration and a fall in creatinine clearance was found in patients after six weeks'' treatment with cyclosporin, although the plasma cyclosporin concentrations were maintained within a narrow therapeutic range. Serum IgA concentrations were reduced in seven patients. Renal function improved within eight weeks after treatment was stopped. Three months after treatment was stopped proteinuria remained less than half of the pretreatment values in three patients. No similar biochemical changes were observed in the controls. Short term cyclosporin therapy may be beneficial in reducing proteinuria in some patients with IgA nephropathy. As transient renal impairment was seen, despite cyclosporin concentrations being maintained within a narrow therapeutic range, indiscriminate use of cyclosporin in glomerulonephritis should be discouraged.     

Renal function after long-term treatment with lithium.

Daily urine volumes, plasma creatinine concentrations, and creatinine clearance were measured in 106 patients with unipolar and bipolar affective disorders attending a "lithium" clinic. Urine volumes exceeded 3.51 in only six patients, plasma creatinine concentrations exceeded 150 mumol/1 (1.7 mg/100 ml) in only five, and creatinine clearance was below 50 ml/min in 16. Renal function was assessed by measuring creatinine clearance and renal tubular function, including response to 20 hours of water deprivation, in a representative sample of 30 patients from the lithium clinic and 30 psychiatric patients matched for age and sex who were taking other psychotropic drugs. Creatinine clearance and tubular function, including urine osmolality after water deprivation, were not significantly different between the two groups. Urinary excretion of arginine vasopressin (AVP), however, was much greater in the lithium-treated patients, who therefore had a diminished tubular responsiveness to AVP. The findings do not support suggestions that long-term lithium treatment results in seriously impaired renal function, renal damage, and polyuria. Compared with other series, however, the patients were being maintained with low serum lithium concentrations, which apparently area as effective prophylactically as higher concentrations.     

Responses to dehydration in the one-humped camel and effects of blocking the renin-angiotensin system

Our objectives were to compare the levels of circulating electrolytes, hormones, and renal function during 20 days of dehydration in camels versus the level in non-dehydrated camels and to record the effect of blocking angiotensin II AT1 receptors with losartan during dehydration. Dehydration induced significant increments in serum sodium, creatinine, urea, a substantial fall in body weight, and a doubling in plasma arginine vasopressin (AVP) levels. Plasma aldosterone, however, was unaltered compared with time-matched controls. Losartan significantly enhanced the effect of dehydration to reduce body weight and increase serum levels of creatinine and urea, whilst also impairing the rise in plasma AVP and reducing aldosterone levels. We conclude that dehydration in the camel induces substantial increments in serum sodium, creatinine, urea and AVP levels; that aldosterone levels are altered little by dehydration; that blockade of angiotensin II type 1 receptors enhances the dehydration-induced fall in body weight and increase in serum creatinine and urea levels whilst reducing aldosterone and attenuating the rise in plasma AVP.     

The time sequence of adaptive changes to dietary phosphorus deficiency in the chick

Ten-day old chicks were divided into 6 groups which were fed a low phosphorus (P) diet for periods of 0, 0.5, 1, 3, 7 or 11 days before killing at 3 weeks old. Labelled calcium (47Ca) was injected intraperitoneally into some birds 18 hours before killing. A marked fall in growth rate, plasma phosphorus level, plasma growth hormone level and renal 24-hydroxylase activity levels had occurred by 12 hours after the experimental diet had started. After one day on the diet, the rate of duodenal Ca absorption had risen and continued to rise up to the 11th day. During this period, the renal 25-hydroxyvitamin D-1-hydroxylase activity rose slightly while the 24-hydroxylase activity rose towards the control level. At 24 hours, the 47Ca level in the bone was markedly lower than in the control group and remained low. It was concluded that the first adaptive response of the chick to dietary P insufficiency was to suppress growth. Subsequent adaptive responses were to increase the rate of Ca and P absorption from the gut and mobilisation from the bone but despite these measures, the growth rate only recovered slightly and the plasma P level continued to fall.     

Studies on Possible Mechanisms of Early Functional Compensatory Adaptation in the Remaining Kidney

Two to 4 hours after unilateral renal exclusion in rats, urine flow rate from the remaining kidney had increased to twice the control level, whereas the filtration rate remained unchanged. After contralateral nephrectomy, NGFR was similar to that of controls, but fractional water reabsorption along proximal tubules decreased. Protein concentration in efferent arteriolar plasma, and hydrostatic pressure gradient between proximal tubules and peritubular capillaries were similar in experimental and control kidneys. Unilateral renal exclusion was followed by a rapid increase of blood pressure. Prevention of this rise depressed but did not abolish functional compensatory adaptation. The occurrence of compensatory adaptation was not affected by decreased renal perfusion pressure.     

Beriberi heart disease in London

Haemodynamic measurements before and after treatment are described in two patients with beriberi heart disease. The first patient had severe disease with a cardiac output of 17·3 litres per minute, which had returned to normal a month later. The second patient had moderate disease with a cardiac output of 7·4 litres per minute; a fall in this and a rise in systemic vascular resistance was found one and two hours after the intravenous injection of aneurine hydrochloride. The plasma pyruvate concentration was raised in the first patient but only slightly so in the second, in whom the pyruvate metabolism test was abnormal. The haemodynamic studies in both cases were of considerable help in making the diagnosis. The diagnosis of beriberi should be considered in any patient with heart disease who has a history of alcoholism, especially as prompt vitamin treatment is curative.     

Primary hyperparathyroidism: the case for medical management.

Thirty two patients with primary hyperparathyroidism were followed up medically for a mean of 4.2 years. One patient had an operation because of a rise in plasma calcium concentration. There was no significant change in the mean plasma calcium and creatinine concentrations or in blood pressure during the period of follow up. The progress of these patients who were managed medically was compared with that of a group of 60 patients who had had successful operations for primary hyperparathyroidism. There was no significant change in mean plasma creatinine concentration or in blood pressure in the group who had had operations during a mean follow up period of 5.9 years. The natural history of mild asymptomatic hyperparathyroidism is probably different from and better than that of the type of hyperparathyroidism that was usually seen before the advent of routine chemical screening. It is suggested that patients over the age of 60 with mild asymptomatic hyperparathyroidism, and perhaps even younger patients, may not require operation.     

Mechanism of action of insulin in diabetic patients: a dose-related effect on glucose production and utilisation

Six insulin-requiring diabetics were studied after insulin had been withheld for 24 hours. On three separate occasions each received a two-hour infusion of insulin at a low dose (2·6 U/h) and a high dose (10·6 U/h) and an infusion of saline as control. The rates of production and utilisation of glucose were measured isotopically. The rate of fall of plasma glucose concentration was faster on the high-dose infusion of insulin than on the low, whereas the fall in plasma free fatty acids, glycerol, and keton bodies was the same on both insulin infusions. The mechanism whereby the two rates of insulin administration lowered plasma glucose concentration differed: during the low-dose infusion the decrease in the glucose concentration was produced entirely by a fall of hepatic glucose output, whereas during the high-dose insulin infusion the glucose concentration fell because both the rate of glucose production fell and the rate of glucose utilisation rose. In all experiments there was a direct relation between a fall in serum potassium concentration and the fall in plasma glucose concentration irrespective of the mechanism that reduced the glucose concentration.These results indicate that in uncontrolled diabetics low-dose insulin infusions lower the blood glucose concentration entirely by reducing glucose production from the liver and that the effect of insulin on potassium transport is independent of its effect on glucose uptake.     

Plasma urea, creatinine, and urea: creatinine ratio in reindeer (Rangifer tarandus tarandus) and in Svalbard reindeer (Rangifer tarandus platyrhynchus) during defined feeding conditions and in the field.

Variation in plasma urea and creatinine concentration and plasma urea:creatinine ratio (U:C) were studied in semidomestic free-ranging reindeer (Rangifer tarandus tarandus) on the Norwegian mainland, in wild Svalbard reindeer (Rangifer tarandus platyrhynchus), and in captive reindeer maintained either on a lichen-based diet or a protein-rich concentrate to investigate whether these parameters could be used as indicators of the nutritional status of reindeer. In the mainland animals, plasma creatinine concentration was high in winter and early spring and decreased by two-thirds toward the summer. The overall range in mean plasma creatinine concentration (+/-SE) was from 90+/-1.26 to 280+/-2.88 micromol/L. Mean plasma urea concentration (+/-SE) varied from 2.46+/-0.10 in winter up to 17.44+/-0.29 mmol/L in summer and autumn. Month of sampling explained 65% and 90% of the variation in plasma urea and creatinine concentrations, respectively, indicating that seasonality in the diet had the greatest influence on these parameters. Reindeer given lichens as the only feed showed an increase in plasma creatinine and a decrease in plasma urea concentration. Food restriction caused a temporary elevation in urea level but had no significant effect on plasma creatinine concentration. The slight effect of energy intake on urea and creatinine levels was supported by the fact that severe undernutrition in the Svalbard reindeer population had only a small effect on plasma urea and creatinine levels. Protein-rich pellet feed increased plasma urea from around 3 mmol/L to above 10 mmol/L and reduced creatinine concentrations to less than 100 micromol/L, suggesting that the protein content of forage is an important determinant of these blood parameters. Mean U:C ratio (+/-SE) in plasma varied from 8.9+/-0.28 to 120.8+/-1.88. Ratios above 20 appeared when protein intake was low and energy intake was restricted or when protein intake was high. Low ratios occurred when protein intake was low but energy intake adequate. Plasma urea and creatinine concentrations and the U:C ratio showed complex dynamics that were affected by both season and the protein and feed intake. We conclude that they appear to be difficult to interpret as single measures of nutritional status of reindeer.     

The effects of hypoxia on glucose turnover in the fetal sheep

The origin of the hypoxia-induced rise in fetal blood glucose concentration in fetal sheep of 124-135 days was investigated. Hypoxia was induced in pregnant sheep and fetuses with chronically implanted vascular catheters by causing the ewes to breathe 9% O2 and 3% CO2 in N2 for 60 min. The rise in fetal plasma glucose caused by a 60% reduction in maternal PaO2 was associated with a 50% fall in plasma insulin concentration. The fall in insulin and rise in glucose was prevented by the alpha-adrenergic blocking agent phentolamine but not by the beta-antagonist propranolol. Turnover of glucose in the fetus under these conditions was measured with [6-3H] and [U-14C] glucose. Hypoxia reduced fetal glucose consumption despite the hyperglycaemia. After 30 min of hypoxia there was no evidence of fetal production of glucose but by 60 min substantial production was evident. The reduced fetal consumption and increased production of glucose was inhibited by phentolamine but not by propranolol. It is concluded that in the fetal sheep hypoxia induced hyperglycaemia is first caused by reduced consumption of glucose and thus fetal glycogen stores are not depleted. If the hypoxia persists fetal blood glucose is elevated further by fetal production of glucose.     

Norepinephrine triggers medullar epinephrine depletion during normoglycemia

Our experiments did show that chronic 12 hours administration of norepinephrine (NE) to rats by means of subcutaneously implantable retard tablets, led to a highly significant epinephrine (E) depletion of the adrenal medulla during normoglycemia. The expected rise of free plasma NE at 6 and 12 hours was accompanied by increased free plasma E values at 12 hours. At this very time point the liver contents of glycogen and free intracellular glucose showed their most pronounced decrease. Since at 12 hours both liver glycogen and medullar E values were at their lowest, a second experiment was performed to examine a possible causal relationship. In order to curb the breakdown of liver glycogen, rats were force fed with 50% glucose solution 9 hours after NE tablet implantation. Glucose feeding not only caused a much less pronounced liver glycogen fall at 12 hours, but, at the same time also prevented E depletion of the adrenal medulla. These observations suggested that rapid fall of liver glycogen and/or liver intracellular free glucose might be the trigger for medullar E depletion, even before hypoglycemia.     

Failure of Glucagon Release in Infants of Diabetic Mothers

Two hours after birth 30 normal infants had a fall in blood glucose of 20·6 mg/100 ml and a rise of plasma pancreatic glucagon of 50·7 pg/ml. Fifteen infants of diabetic mothers treated with insulin had a much greater fall in blood glucose of 77·5 mg/100 ml and a smaller rise of glucagon of 20·9 pg/ml. By comparison 14 small-for-dates infants, who are also prone to hypoglycaemia, had a blood glucose fall of 32·8 mg/100 ml and a larger rise of pancreatic glucagon of 96·0 pg/ml. It is suggested that the impaired pancreatic glucagon rise in the infants of diabetic mothers may be a significant factor in their hypoglycaemia.     

Apparent anion imbalance in the fresh water adapted eel

Summary On adapting brackish waterAnguilla anguilla to fresh water it was noted that, while the plasma sodium, magnesium,pCO₂ and pH were held reasonably constant, there was a substantial fall in chloride concentration (–33 mEq). The gradient of the linear correlations between plasma sodium and chloride also fell (brackish water gradient=0.92, fresh water gradient=0.21) indicating that a new pattern of plasma ion interrelationships was being established. Comparison with plasma Na/Cl ion ratios from other fishes suggested that this phenomenon was peculiar toA. anguilla. Corresponding with the very low plasma chloride levels plasma bicarbonate was four to five times that found in other fishes, and this was thought related to the finding that the haematocrit value almost doubled during adaptation to fresh water. In fresh water adapted fish a fall in plasma chloride was associated with a rise in plasma bicarbonate, however the charge compensation effect of this response was only partial as summing the common plasma cations and anions left an anion deficit of about 34 mEq to be accounted for.     

Changes of Blood Pressure,Renin, and Angiotensin after Bilateral Nephrectomy in Patients with Chronic Renal Failure

Circulating levels of renin, angiotensin I, and angiotensin II were increased in six patients with chronic renal failure and hypertension uncontrolled by dialysis and hypotensive drugs. Lower and often normal levels were found in 10 patients whose blood pressure was controlled by dialysis treatment. For a variety of reasons all patients were subjected to bilateral nephrectomy. The logarithm of the decrease in plasma concentrations of renin and angiotensin II was significantly related to the fall of blood pressure after operation. Plasma renin concentration correlated significantly with blood angiotensin I concentration and with plasma angiotensin II in samples taken before and after nephrectomy. Renin, angiotensin I, and angiotensin II were measurable in samples of blood taken 48 hours or more after the operation.     

Mechanisms Underlying Early Rapid Increases in Creatinine in Paraquat Poisoning

Background

Acute kidney injury (AKI) is common after severe paraquat poisoning and usually heralds a fatal outcome. The rapid large increases in serum creatinine (Cr) exceed that which can be explained by creatinine kinetics based on loss of glomerular filtration rate (GFR).

Methods and Findings

This prospective multi-centre study compared the kinetics of two surrogate markers of GFR, serum creatinine and serum cystatin C (CysC), following paraquat poisoning to understand and assess renal functional loss after paraquat poisoning. Sixty-six acute paraquat poisoning patients admitted to medical units of five hospitals were included. Relative changes in creatinine and CysC were monitored in serial blood and urine samples, and influences of non-renal factors were also studied.

Results

Forty-eight of 66 patients developed AKI (AKIN criteria), with 37 (56%) developing moderate to severe AKI (AKIN stage 2 or 3). The 37 patients showed rapid increases in creatinine of >100% within 24 hours, >200% within 48 hours and >300% by 72 hours and 17 of the 37 died. CysC concentration increased by 50% at 24 hours in the same 37 patients and then remained constant. The creatinine/CysC ratio increased 8 fold over 72 hours. There was a modest fall in urinary creatinine and serum/urine creatinine ratios and a moderate increase in urinary paraquat during first three days.

Conclusion

Loss of renal function contributes modestly to the large increases in creatinine following paraquat poisoning. The rapid rise in serum creatinine most probably represents increased production of creatine and creatinine to meet the energy demand following severe oxidative stress. Minor contributions include increased cyclisation of creatine to creatinine because of acidosis and competitive or non-competitive inhibition of creatinine secretion. Creatinine is not a good marker of renal functional loss after paraquat poisoning and renal injury should be evaluated using more specific biomarkers of renal injury.     

Short-term effect of nicotinic acid on plasma level and turnover of free fatty acids in sheep and man

The effects of nicotinic acid on plasma free fatty acid levels and turnover and on plasma glycerol levels were studied in the first few hours after administration to man and the sheep. In both species a fall in all parameters studied was followed by a rise above basal level, interpreted as due to an increase in lipolysis above resting level. The significance of the findings is discussed.     

Biochemical and Molecular Responses to Loss of Renal Mass: Atpase and Cyclic Nucleotides: Changes in Renal Cyclic Nucleotides as a Trigger to the Onset of Compensatory Renal Hypertrophy

In adult male Wistar rats contralateral nephrectomy was followed, within 10 minutes, by a nearly twofold rise of the content of cGMP in renal tissue. 20 and 40 minutes after contralateral nephrectomy cGMP fell to one half its control level to rise again to its normal level within 90 minutes. The initial rise of the concentration of cGMP was accompanied by a simultaneous fall of the concentration of cAMP by about 30 percent: the cAMP concentration remained 10-20 percent below control level for approximately two hours and rose again to its initial level after three hours. Cross-circulation of a nephrectomized rat with an intact animal led to a sharp increase of cGMP in the kidneys of the latter with a peak at 10 minutes after initiating cross-circulation and also to a fall of the cAMP concentration. When the same nephrectomized donor rat was subsequently cross-circulated with one, or even two, intact receiver animals, similar short-lasting changes of cyclic nucleotide concentrations were recorded in the kidneys of all the receivers. When a normal kidney was transplanted to the neck of a rat, subsequent removal of one of its own kidneys did not result in any change in cyclic nucleotide content in either the remaining or the transplanted kidney. The data are interpreted to indicate that renal tissue produces a factor inhibiting renal growth which counteracts a circulating humoral kidney growth stimulating factor of unknown origin. An initial rise of cGMP and a fall of cAMP may trigger the subsequent stimulation of protein synthesis responsible for hypertrophy.     

Effect of aluminium hydroxide on serum ionised calcium,immunoreactive parathyroid hormone,and aluminium in chronic renal failure.

According to the Bricker-Slatopolsky theory, secretion of parathyroid hormone (PTH) is switched on in chronic renal failure by hypocalcaemia due to phosphate retention. In an attempt to reverse this process 20 patients in preterminal renal failure (plasma creatinine 569 +/- 195 mumol/l) were given aluminium hydroxide, 3.8 g daily. They were studied for four weeks and all measurements were made at the start and weekly, except measurements of serum aluminium concentration, which were made at the start and at the end of the fourth week. Mean serum phosphate fell from 1.89 to 1.47 mmol/l (5.9 to 4.6 mg/100), mean serum calcium rose from 2.07 to 2.24 mmol/l (8.3 to 9.0 mg/100 ml), and serum ionised calcium rose from 1.07 to 1.20 mmol/l (4.3 to 4.8 mg/100 ml), but serum immunoreactive PTH did not fall. Thirteen patients had initial serum immunoreactive PTH concentrations at or near to normal and 11 were taking beta-blockers but even in those with neither explanation, PTH concentrations did not fall. Serum aluminium concentrations rose from 0.4 to 1.02 mumol/l (10.9 to 27.4 microgram/l). Aluminium hydroxide corrects serum phosphate, total calcium, and ionised calcium at the price of a rise in serum aluminium concentration; in this study it did not affect serum immunoreactive PTH. The Bricker-Slatopolsky theory still needs verification in studies of patients with chronic renal failure.     

Adrenergic mechanisms in control of plasma lipid concentrations.

The mechanisms of the changes in plasma lipids concentrations observed after beta-blockade were examined in 53 patients with hypertension receiving treatment with atenolol, metoprolol, propranolol, and oxprenolol in a randomised cross-over trial. Significant increases in mean plasma total and very-low-density lipoprotein (VLDL) triglyceride and reductions in high-density lipoprotein (HDL) cholesterol and free fatty acids concentrations wer observed with all four drugs, the increase in plasma triglyceride concentration being greatest after propranolol and oxprenolol. No significant changes were observed in total of LDL cholesterol concentrations, but HDL:LDL ratios and HDL cholesterol as a proportion of total cholesterol fell significantly. Thus plasma lipid concentrations should be monitored after three to six months of long-term treatment. Changes in triglyceride, HDL cholesterol and free fatty acid concentrations were associated with a highly significant reduction in clearance of soya oil (Intralipid) in 25 patients studied but were unrelated to changes in blood pressure. The fall in HDL cholesterol and rise in free fatty acid concentrations were significantly less in those with initially reduced HDL cholesterol or raised free fatty acid concentrations respectively. It is proposed that unopposed alpha stimulation inhibits lipoprotein lipase with a subsequent rise in plasma triglyceride and fall in HDL cholesterol concentration. Analysis of the relation between pretreatment concentrations and subsequent changes suggests that excessive alpha stimulation may impair production of HDL cholesterol in those with low HDL cholesterol concentrations before treatment. Subtle catecholamine-mediated changes in plasma lipid concentrations might provide a mechanism for the relation between stress and the development of cardiovascular events.