Assessment of glomerular and tubular functions in renal transplant patients receiving cyclosporine A in combination with either sirolimus or everolimus.

AIMS: The aim of this study was to examine the glomerular filtration rate (GFR) and tubular function at three months after renal transplantation in two groups of patients receiving cyclosporine A associated with either sirolimus (SRL) (n = 18) or everolimus (RAD) (n = 12), two structurally similar immunosuppressant drugs. RESULTS: Donors' and recipients' characteristics and mean cyclosporine A trough levels were similar in the two groups. The mean sirolimus trough level was 12.01 +/- 1.6 ng/ml whereas the mean everolimus trough level was 4.23 +/- 0.36 ng/ml. GFR, equated by the clearance of inulin, was higher in RAD patients (64 +/- 4 ml. min- 1.1.73 m(-2)) than in SRL patients (49 +/- 4 ml.min(-1) .1.73 m(-2)) (p < 0.05). The significant difference in GFR between the groups was not affected by differences in mean arterial blood pressures, or by differences in daily prednisone dosages, cyclosporine trough levels, or SRL and RAD trough levels. Phosphatemia, renal phosphate threshold (TmPO4/ GFR ratio) and uric acid clearance were significantly lower in the SRL than in the RAD group, despite similar levels of parathyroid hormone. Finally, urinary acid excretion was significantly lower in the RAD group. CONCLUSION: In conclusion, regarding nephrotoxicity, our preliminary data suggest that it seems to be preferable to combine cyclosporine with RAD rather than with sirolimus in renal transplant patients. However, long-term renal effects of this combination are still to be determined in a larger cohort.

Cyclosporine-A-based immunosuppression and renal functional reserve in organ-transplant patients.

The glomerular filtration rate (GFR) may increase after oral protein overload or after an amino acid infusion. Renal functional reserve (RFR) is defined as the difference between the poststimulation and the baseline glomerular filtration rate. RFR has been studied in transplant patients. The results have been conflicting because RFR may be affected by donor age, the time from transplantation, the type of immunosuppression, the basal GFR, the body surface area, and the presence of calcium channel blocker therapy. We observed that during the first year posttransplantation renal recipients maintained on cyclosporine (CsA) therapy retain a level of RFR that represents approximately 30% of the baseline GFR. Moreover, hypertensive cyclosporine treated renal transplant patients on calcium channel blocker therapy do not exhibit permanent glomerular hyperfiltration until 8 months posttransplantation. Finally, both renal and heart transplant patients on cyclosporine therapy possess renal reserve, but the single renal graft in renal transplant patients shows a proportionally higher baseline GFR and a better ability to exhibit a RFR than the two native kidneys in heart transplant patients. Many studies, although not all, have documented a positive RFR in both children and adult cyclosporine-treated kidney graft recipients, demonstrating that hyperfiltration is not the rule following single kidney transplantation.

Transient renal effects of sildenafil in male kidney transplant recipients.

BACKGROUND: Sildenafil (Viagra) improves erection by sustaining Guanosine 3', 5'-cyclic monophosphate (cGMP)-mediated smooth muscle relaxation in the corpus cavernosum. It also induces systemic vasodilation, resulting in a minor decrease in blood pressure. We evaluated the effect of one dose of sildenafil on graft function and hemodynamics in impotent male transplant recipients. METHODS: Two sets of combined lithium, inulin, and p-amino hippurate clearance studies were conducted, with and without sildenafil (100 mg orally) in 11 male kidney transplant recipients (KTRs). RESULTS: Sildenafil increased glomerular filtration rate by 14+/-4 from the baseline value of 55+/-7 ml x min(-1) x 1.73 m2(-1) (P<0.01), whereas calculated renal vascular resistances decreased by 40+/-18 from the baseline value of 247+/-29 mmHg/L x min(-1) x 1.73 m2-1 (P<0.05). CONCLUSIONS: The oral administration of sildenafil in KTRs did not impair the function of the graft. In terms of renal physiology, the observed modifications did not warrant any specific precautions when offering sildenafil to KTRs suffering from erectile dysfunction.

Genetic heterogeneity of familial hyperkalaemic hypertension.

BACKGROUND: Familial hyperkalaemic hypertension (FHH) is a Mendelian form of low-renin hypertension characterized by hyperkalaemia and hyperchloraemic acidosis despite a normal glomerular filtration rate. To date, three different loci have been identified, on chromosomes 1, 17 and 12. OBJECTIVE: To test for genetic linkage between the three FHH loci and three new affected kindreds. DESIGN AND METHODS: Clinical, biological and genetic analyses were made of three kindreds, including 11 affected individuals among 25 members. Genotyping was performed using four series of microsatellite markers spanning the chromosomes 1, 17 and 12 loci, and the thiazide-sensitive Na-Cl cotransporter (SLC12A3) gene. RESULTS: Segregation of the trait in each kindred was compatible with an autosomal transmission, the affected individuals displaying reasonably consistent biochemical abnormalities and the expected variability in arterial hypertension. Multipoint linkage analysis excluded linkage with the four candidate loci in kindreds 1 and 2, but not with the chromosome 1 locus in kindred 3. CONCLUSION: These results demonstrate further genetic heterogeneity and that a fourth gene is responsible for FHH in at least two unrelated kindreds. They suggest a variety of molecular defects leading to FHH.

Bradykinin attenuates the [Ca(2+)](i) response to angiotensin II of renal juxtamedullary efferent arterioles via an EDHF.

1. Bradykinin (BK) effect on the [Ca(2+)](i) response to 1 nM angiotensin II was examined in muscular juxtamedullary efferent arterioles (EA) of rat kidney. 2. BK (10 nM) applied during the angiotensin II-stimulated [Ca(2+)](i) increase, induced a [Ca(2+)](i) drop (73+/-2%). This drop was prevented by de-endothelialization and suppressed by HOE 140, a B2 receptor antagonist. It was neither affected by L-NAME or indomethacin, nor mimicked by sodium nitroprusside, 8-bromo-cyclic GMP or PGI(2). The BK effect did not occur when the [Ca(2+)](i) increase was caused by 100 mM KCl-induced membrane depolarization and was abolished by 0.1 microM charybdotoxin, a K(+) channel blocker. 3. Although proadifen prevented the BK-caused [Ca(2+)](i) fall, more selective cytochrome P450 inhibitors, 17-octadecynoic acid (50 microM) and 7-ethoxyresorufin (10 microM) were without effect. 4. Increasing extracellular potassium from 5 to 15 mM during angiotensin II stimulation caused a [Ca(2+)](i) decrease (26+/-4%) smaller than BK which was charybdotoxin-insensitive. Inhibition of inward rectifying K(+) channels by 30 microM BaCl(2) and/or of Na(+)/K(+) ATPase by 1 mM ouabain abolished the [Ca(2+)](i) decrease elicited by potassium but not by BK. 5. A voltage-operated calcium channel blocker, nifedipine (1 microM) did not prevent the BK effect but reduced the [Ca(2+)](i) drop. 6. These results indicate that the BK-induced [Ca(2+)](i) decrease in angiotensin II-stimulated muscular EA is mediated by an EDHF which activates charybdotoxin-sensitive K(+) channels. In these vessels, EDHF seems to be neither a cytochrome P450-derived arachidonic acid metabolite nor K(+) itself. The closure of voltage-operated calcium channels is not the only cellular mechanism involved in this EDHF-mediated [Ca(2+)](i) decrease.

Contrasting renal functional reserve in very long-term Type I diabetic patients with and without nephropathy.

AIMS: This study was to determine whether renal functional reserve (RFR) is present in patients who have suffered long-lasting Type I (insulin-dependent) diabetes mellitus. METHODS: Renal functional reserve was elicited by a 3-h amino acid infusion (4.5 mg x kg(-1) x min(-1)) in 10 patients with nephropathy (DN+) and 10 patients without nephropathy (DN-) who had lived with diabetes for 24 +/- 3 and 27 +/- 3 years, respectively and in 15 healthy control subjects. Renal functional reserve was calculated as the difference between amino acid-stimulated and baseline glomerular filtration rates (GFR). RESULTS: Baseline glomerular filtration rate in DN- patients (106 +/- 8) and control subjects (112 +/- 3 ml x min(-1) x (1.73m2)(-1)) was significantly higher (p < 0.01) than in DN+ patients (79 +/- 7 ml x min(-1) x (1.73m2)(-1)). Renal functional reserve was absent in DN+ patients, whereas it represented 26 +/- 4% of the baseline in DN- patients and 23 +/- 2% in control subjects. Renal vascular resistance decreased statistically significantly during amino acid infusion in DN- patients and control subjects but not in DN+ patients. CONCLUSIONS/HYPOTHESIS: These results indicate that very long-term Type I diabetic patients without diabetic nephropathy still have a normal renal functional reserve. In contrast, this reserve is suppressed in similarly long-term macroalbuminuric and hypertensive patients with overt nephropathy in spite of their remarkably maintained glomerular filtration rate. This opposite impairment supports the interpretation that glomerular hyperfiltration is a determining mechanism in human diabetic nephropathy.

Differential induction of functional B1-bradykinin receptors along the rat nephron in endotoxin induced inflammation.

BACKGROUND: Under physiological conditions, the effects of kinins in the kidney are mainly mediated by the bradykinin B2-receptor, whereas the kinin B1-receptor is strongly induced under inflammatory conditions in a variety of tissues. Knowledge of the distribution of the B1-receptor along the nephron is of importance since the B1-receptor might replace B2-receptors under these conditions. METHODS: Using a RT-PCR/Southern blot approach allowing relative quantification of mRNA levels, ten different microdissected rat nephron segments were analyzed for the presence of the B1- and B2-receptor before and after endotoxin treatment to induce experimental inflammation. The functionality of the expressed receptors was assessed by kinin-induced intracellular calcium ([Ca2+]i) mobilization in microdissected nephron segments. RESULTS: While under physiological conditions no B1-receptor mRNA could be detected, after 18 hours of treatment with bacterial lipopolysaccharide (LPS) the expression of B1-receptor mRNA was strongly induced in the efferent arteriole, the medullary and inner medullary thin limb, and in the distal tubule. Moderate expression was found in the glomerulus, proximal convoluted and straight tubules, and in the medullary thick ascending limb. Small but detectable expression was observed in the cortical collecting duct. The induction of B1-receptor mRNA expression resulted in functional receptor expression, since increases in [Ca2+]i were observed upon B1-agonist stimulation. LPS treatment also increased the expression of B2-receptor mRNA in all nephron segments except in the glomerulus, the inner medullary thin limb and the outer medullary collecting duct. However, no related changes in B2-agonist induced rises in [Ca2+]i were found. CONCLUSIONS: These studies show a functional induction of the B1-kinin receptor along the rat nephron, which should be taken in account to address the effects of kinins under inflammatory conditions in the kidney.

Cyclosporin nephrotoxicity: pathophysiology and comparison with FK-506.

At the end of an era of almost exclusive use of cyclosporin A, there have been significant advances in the understanding of its immunosuppressive effects, whereas there is still uncertainty about the mechanisms underlying its nephrotoxicity. The recently introduced FK-506, in spite of its undeniable clinical advantages, has subsequently been proved to have rather similar nephrotoxicity. This paper reviews recent data on cyclosporin A and FK-506 nephrotoxicity, with emphasis on: first, the haemodynamic, functional and structural features; second, the potential mediators; and third, the relationship with some immunosuppressive mechanisms involved to give insights into the pathophysiology.

Renal functional reserve in IDDM patients.

The aim of this study was to determine whether renal functional reserve (RFR) is altered in insulin-dependent diabetic (IDDM) patients according to the stage of diabetic nephropathy. RFR was examined in 33 IDDM patients in similar glycaemic and metabolic control and compared to 12 healthy control subjects, during eight 1 h clearance periods prior to, during and after a 3-h stimulation by amino acid infusion (4.5 mg x kg(-1) x min[-1]). RFR was calculated as the difference between stimulated and baseline glomerular filtration rates (GFR). In 14 early normotensive diabetic patients with normal urinary albumin excretion, mean baseline GFR (133 +/- 3 ml x min(-1) x 1.73 m[-2]) was higher whereas RFR (10 +/- 4 ml x min(-1) x 1.73 m[-2]) was lower (p < 0.05) than in control subjects (113 +/- 4 and 28 +/- 2 ml x min(-1) x 1.73 m(-2), respectively). In 10 normotensive patients who had lived with IDDM for 16 years and who had microalbuminuria, baseline GFR and RFR (109 +/- 7 and 24 +/- 6 ml x min(-1) x 1.73 m(-2), respectively) were similar to those in control subjects. In 9 patients who had suffered IDDM for 23 years and had developed macroalbuminuria and hypertension, baseline GFR (78 +/- 8 ml x min(-1) x 1.73 m[-2]) was lower than in control subjects (p < 0.05) and RFR (8 +/- 4 ml x min(-1) x 1.73 m[-2]) was not significant. In addition, renal vascular resistance decreased significantly during infusion (p < 0.05) in microalbuminuric normotensive patients as well as in control subjects (by 9 +/- 4 and 11 +/- 4 mmHg x l(-1) x min(-1) x 1.73 m(-2), respectively) but not in normoalbuminuric normotensive or macroalbuminuric hypertensive patients. These results indicate that microalbuminuric normotensive patients retain a normal RFR, whereas RFR is reduced or suppressed at two opposite stages of the disease: in normoalbuminuric normotensive patients with a high GFR and in macroalbuminuric hypertensive patients with a decreased GFR. This dissimilar impairment reveals permanent glomerular hyperfiltration in both early IDDM without nephropathy and IDDM with overt diabetic nephropathy, but not in IDDM with incipient nephropathy.

Cyclosporine A-induced increase in glomerular cyclic GMP in rats and the involvement of the endothelinB receptor.

1. A transient two fold increase in the cyclic GMP content was observed in rat freshly isolated glomeruli 6 to 9 h after a single subcutaneous injection of 20 mg kg-1 cyclosporine A (CsA) in conscious animals. 2.In vitro stimulation with endothelin 3 (ET-3) of isolated glomeruli obtained from CsA-untreated rats resulted in a dose-dependent increase in cyclic GMP content. The increase observed with 10 nM ET-3 was similar to that observed in glomeruli isolated 9 h after in vivo CsA administration. 3. The rise in glomerular cyclic GMP content after in vivo CsA injection was prevented by in vivo treatment with L-NAME (10 mg kg-1) or by in vitro calcium deprivation of the incubation medium. 4. The stimulating effects of CsA on glomerular cyclic GMP content were inhibited by in vivo administration of the ETB receptor antagonist BQ-788 (2 mg kg-1) but not by the ETA receptor antagonist BQ-123 (2 mg kg-1). 5. The maximum increase in glomerular cyclic GMP content induced in vitro by acetylcholine (100 microM) and by ET-3 (100 nM) was slightly lower (approximately by 20-25%; P < 0.05) in glomeruli from CsA-treated rats than in glomeruli from untreated rats. In contrast, the maximum increase achieved with 1 microM sodium nitroprusside was similar in both groups. 6. A single subcutaneous injection of CsA did not significantly alter the glomerular mRNA expression of constitutive endothelial NO synthase (eNOS), as evaluated by RT-PCR, whereas the mRNA expression of the inducible NO synthase (iNOS), which follows pretreatment with lipopolysaccharide, was prevented. 7. These results indicate that in vivo administration of a single dose of cyclosporine A transiently increases the cyclic GMP content of freshly isolated glomeruli, and that activation of ETB receptors and stimulation of the NO pathway are involved in this process. Furthermore, a single administration of CsA does not impair eNOS mRNA expression and only slightly reduces NO-dependent glomerular cyclic GMP production.

Endothelin increases NO-dependent cGMP production in isolated glomeruli but not in mesangial cells.

The ability of endothelins (ETs) to modulate nitric oxide-dependent glomerular guanosine 3'-5'-cyclic monophosphate (cGMP) production has recently been reported. The aim of this study was to directly confirm, using an antagonist, the involvement of the ETB receptor subtype and to investigate the potential role of mesangial cells (MC) in this ET-induced cGMP production. In glomeruli freshly isolated from rats, endothelin-3 (ET-3) induced a dose-dependent increase in cGMP content. This increase was inhibited by NG-monomethyl-L-arginine (L-NMMA) and methylene blue and was calcium dependent. Moreover, the effect of ET-3 was prevented by two ETB-selective receptor antagonists, BQ-788 and IRL-1038, but not by BQ-123, an ETA-selective receptor antagonist. It therefore appeared that ET-3 stimulates the glomerular constitutive NO pathway through activation of the ETB receptor subtype. In contrast, ET-3 and calcium ionophore had no effect on cGMP formation in cultured MC, whereas incubation with sodium nitroprusside resulted in an approximately 50-fold increase in the intracellular content of cGMP. However, ET-3 induced a dose-dependent rise in free MC cytosolic calcium that was abolished by an ETB antagonist. Moreover, both ETA and ETB receptors mRNA were expressed in primary cultures of MC. Finally, we failed to detect the presence of constitutive NO synthase (NOS), as demonstrated by the absence of L-citrulline forming activity and of the mRNA encoding for endothelial NOS, whereas they were present in isolated glomeruli. These data indicate that MC, despite the fact that they express ETB receptors, are not involved in glomerular NO production induced by exposure to ET-3, because they do not express constitutive NO synthase.

Activation of Flk-1/KDR mediates angiogenesis but not hypotension.

OBJECTIVE: The concept of therapeutic angiogenesis with vascular endothelial growth factor (VEGF) has been validated in peripheral arterial disease. Its use in myocardial ischemia may be delayed as the result of the description in a porcine model of peripheral vasodilation after intraluminal injections of VEGF resulting in a 50% fatality rate by hypotension. We carried out this study to test whether VEGF-induced hypotension (1) is species specific, (2) is mediated by the receptor mediating angiogenesis, (3) is prevented by inhibition of nitric oxide synthase. METHODS: In the rabbit corneal pocket assay we tested whether a previously published anti-idiotypic antibody (AIA) agonist of the VEGF receptor Flk-1/KDR could elicit angiogenesis. Various doses of recombinant VEGF or AIA were injected into anesthetized normotensive Wistar-Kyoto rats and the mean arterial blood pressure (MABP) was recorded. To test the implication of nitric oxide in VEGF-induced hypotension we treated the animals with a competitive inhibitor of nitric oxide synthase prior to the injection of VEGF. RESULTS: Both VEGF and AIA induce angiogenesis but only intravenous injections of VEGF induced a rapid, transient and dose-dependent decrease in MABP. The ED50 was 0.5 micrograms. The interval between two VEGF injections required to lead to a decrease of MABP was 40 minutes. Nitric oxide synthesis inhibitor prevented, in a reversible fashion, the effect of VEGF. CONCLUSION: VEGF-induced hypotension is not species specific. It is prevented by nitric oxide inhibition. VEGF-induced angiogenesis and hypotension are not mediated in vivo by the same VEGF receptor.

Renal functional reserve in kidney and heart transplant recipients.

Renal functional impairment paradoxically often seems less severe in kidney than in heart-transplant recipients (KTR and HTR, respectively) when both are submitted to cyclosporine therapy. Renal functional reserve (RFR), elicited by a 3-h intravenous amino acid infusion, was examined in 12 KTR and 13 HTR at 7 to 8 months, appropriately compared with either eight one-kidney or 12 two-kidney healthy control subjects (1K.C and 2K.C, respectively). Baseline GFR was 54 +/- 4 mL/min in KTR and 71 +/- 4 mL/min in HTR (P < 0.05). During amino acid infusion, the maximum increase in GFR (which represented RFR) was 17 +/- 3 mL/min in both KTR and HTR (P < 0.001). RFR in KTR was 96 +/- 18% of that in 1K.C, whereas RFR in HTR was only 59 +/- 9% of that in 2K.C. Effective RPF increased (41 +/- 8 mL/min, P < 0.001), and renal vascular resistances decreased (48 +/- 17 mm Hg/L per min, P < 0.05) in KTR but not in HTR. These results demonstrate that both KTR and HTR possess a renal reserve but that the single renal graft in KTR retains a proportionally higher baseline GFR and a better ability to exhibit a RFR than the two native kidneys in HTR. This dissimilar impairment could result from slightly higher cyclosporine dosage, activation of the intact renal sympathetic innervation accentuated by cardiac denervation, renal consequences of former heart failure and potential alterations in the cardiac graft function, and/or higher prevalence of hypertension and additive therapies in HTR.

Amino acid loading disrupts whole kidney proximal glomerular-tubular balance in humans.

The effect of amino acid infusion on proximal glomerular-tubular balance (PG-TB) was studied in twelve healthy two-kidney volunteers (2K) and eight uninephrectomized subjects (1K) in similar sodium and protein balance, to provide an extended range of values for renal function. Amino acid infusion induced a reversible significant increase in GFR: +23 +/- 4 and +18 +/- 3 ml/min/1.73 m2 in 2K and 1K respectively (p < 0.001), but not in absolute proximal reabsorption (APR, calculated as inulin clearance--lithium clearance): +8 +/- 3 and +6 +/- 3 ml/min/1.73 m2 respectively, NS. Consequently, the fractional increases in APR for both two kidney- and one kidney-subjects (+11 +/- 4 and +14 +/- 6%) were less than the fractional increases in GFR (+20 +/- 3 and 25 +/- 4%), and the effectiveness of PG-TB was significantly decreased to 53.2 and 55.9% (p < 0.001). Urinary sodium excretion also increased by 116 +/- 24 and 95 +/- 29 mumol/min/1.73 m2 in 2K (p < 0.001) and 1K (p < 0.01) respectively. Urinary excretion of guanosine 3',5'-cyclic monophosphate (cGMP) simultaneously increased (p < 0.001) by 223 +/- 77 and 350 +/- 135 pmol/min/1.73 m2 during infusion of amino acids in 1K and 2K respectively. In the whole group of subjects, impairment of the PG-TB was inversely related to the increase in urinary cGMP (p < 0.05). The results demonstrate that amino acid infusion disrupts proximal glomerular-tubular balance in humans due to non-proportional alterations in glomerular filtration rate and proximal reabsorption, and they suggest that a NO-dependent mechanism may be involved in the disruption.

In vivo and in vitro homologous desensitization of rat glomerular bradykinin B2 receptors.

We investigated the effects of bradykinin on glomerular bradykinin B2 receptor functions and parameters in vivo, after intrarenal infusion of bradykinin, and in vitro, after incubation of isolated rat glomeruli with bradykinin. Bradykinin transiently increased renal plasma flow whereas a second challenge was ineffective. Scatchard analysis demonstrated the presence of two populations of bradykinin binding sites whose densities were similarly decreased by about 40% after intrarenal bradykinin infusion. This decrease was not altered by an acid wash suggesting internalization of the radiolabelled ligand. The effect of bradykinin was prevented by a bradykinin B2 receptor antagonist. Pre-exposure of isolated rat glomeruli to bradykinin mimicked the in vivo results because there was a reduction in bradykinin-induced prostaglandin E2 and prostaglandin F2 alpha release. Rapid recovery was observed 15 min after washing out the bradykinin. Our results directly demonstrate a negative homologous down-regulation of B2 glomerular bradykinin receptor density under both in vivo and in vitro conditions, an effect which involves a rapid sequestration of the receptor.

Renal functional reserve in calcium channel blocker-treated hypertensive recipients of kidney transplant.

Renal functional reserve during infusion of an amino acid solution was examined in 12 cyclosporin-treated kidney recipients at 1 (T1) and 8 months (T2) after transplantation. Patients were retrospectively divided into six normotensive (NT) and six hypertensive recipients (HT) maintained on monotherapy with a calcium channel blocker. Baseline glomerular filtration rates (GFR) were similar in NT and HT at T1 and T2. Renal functional reserve was identical in NT and HT at T1 (15 +/- 7 vs 18 +/- 13 ml/min/1.73 m2) but significantly greater in HT at T2 (11 +/- 5 vs 23 +/- 10 ml/min/1.73 m2; P < 0.05). At T2, baseline proximal tubule outflow (lithium clearance) was greater in HT (26 +/- 8 vs 16 +/- 3 ml/min/1.73 m2; P < 0.05), whereas fractional proximal reabsorption was less (54 +/- 11% vs 67 +/- 5%; P < 0.05). These results indicate that: (i) hypertensive recipients on calcium channel blocker therapy do not exhibit permanent glomerular hyperfiltration until 8 months after transplantation, and have a reduced proximal reabsorption; (ii) measurement of amino acid-stimulated GFR and renal functional reserve is a more sensitive method than that of baseline GFR for evaluating renal function and the effects of therapy in kidney recipients.