A limited sampling strategy for the estimation of Neoral AUCs in pediatric patients.

The improved pharmacokinetics of Neoral allows the development of an accurate estimate of the full area under the concentration time curve (AUC) from a limited sampling strategy. As no such strategy has been derived from pharmacokinetic data obtained from children on 12-hourly dosing, and as patient convenience demands shorter sampling times, we derived a limited sampling strategy from 45 AUCs obtained from 19 pediatric renal transplant patients by stepwise forward multiple regression, and prospectively tested them on a separate group of 49 AUCs obtained from 18 pediatric renal transplant patients. Full cyclosporine (CsA) AUCs were obtained from samples drawn pre dose (C0) and at 2, 4, 6, 8 and 12 h post dose (C2, C4, C6, C8, and C12). High-precision predictions of full AUC were obtained based on the formula: AUC = 444 + 3.69 x C0 + 1.77 x C2 + 4. 1 x C4 (mean prediction error +/- SD = 0.3 +/- 6.4%, 95% confidence interval=-1.7% to 1.9%.) In conclusion, CsA exposure in pediatric renal transplant patients on 12-hourly Neoral dosing can be reliably predicted by an early time point-based limited sampling strategy in children. This formula has the advantage of obtaining trough as well as AUC from one brief, convenient sampling period.

Water transport in the immature rabbit collecting duct.

Immature animals have limited ability to concentrate the urine. This is in part the result of end-organ resistance to arginine vasopressin (AVP). To characterize this response, we measured water absorption in microperfused cortical collecting ducts (iCCD) and outer medullary CD (iOMCD) derived from 2- to 12-day-old rabbits. The roles of adenosine 3',5'-cyclic monophosphate (cAMP) and prostaglandins were investigated. Baseline osmotic water permeability (L(p), 10(-7) cm/atm per s) in the iCCD (20.3+/-2.4) and iOMCD (19.7+/-5.6) was not different from mature CCD (mCCD) (14.6+/-3.1). After AVP, L(p) in the iCCD (46.7+/-10.0) was significantly lower than in the mCCD (114.3+/-21.8). Neither stimulation with cAMP (85.6+/-51.3) nor inhibition of endogenous prostaglandin production with indomethacin (57.6+/-29.8) abolished the blunted response to AVP in the iCCD. We conclude that AVP-stimulated water transport in the iCCD is impaired. The disruption in AVP response is, at least in part, localized distal to cAMP, and is not mediated by prostaglandins.

Changing patterns in the histopathology of idiopathic nephrotic syndrome in children.

BACKGROUND: It is widely accepted that minimal change nephrotic syndrome (MCNS) is the most common cause of nephrosis in children. Recent studies have demonstrated an increasing incidence of focal segmental glomerulosclerosis (FSGS) in adults. METHODS: To determine possible changes in the etiology of childhood nephrosis, the clinical charts of 152 pediatric patients diagnosed with idiopathic nephrotic syndrome between 1978 and 1997 were reviewed. Histopathological diagnosis was available in 105 patients. RESULTS: MCNS was present in 35% of all biopsies, whereas FSGS was observed in 31%. Even if we assume that all patients without a histological diagnosis had MCNS (presumptive MCNS), the total incidence of MCNS (biopsy proven + presumptive) in our population was only 55%. We observed a dramatic increase in the incidence of FSGS during recent years. Before 1990, FSGS was diagnosed in 23% of all renal biopsies but increased to 47% afterward (P = 0.02). This pattern was observed in all ethnic groups. In African Americans, there was a trend for an increase in the incidence of FSGS from 38% before 1990 to 69% after 1990. A similar trend was observed in Caucasians (from 20 to 45%) and Hispanics (from 8 to 33%) Hispanics had the highest incidence of MCNS (biopsy proven + presumptive: 73%), followed by Caucasians (53%) and African Americans (37%). The mean age for presentation of nephrotic syndrome in African Americans (8.0 +/- 0.9 years) was higher than in Caucasians (4.1 +/- 0.05) and Hispanics (3.3 +/- 0.5). CONCLUSIONS: Our study showed that the incidence of FSGS in children with idiopathic nephrotic syndrome has increased recently. Furthermore, in African American children. FSGS is the most common cause of nephrotic syndrome. These findings may have significant implications in the management of childhood nephrotic syndrome.

Aquaporin-2 in the immature rat: expression, regulation, and trafficking.

The immature kidney is resistant to arginine vasopressin. To define the role of aquaporin-2 (AQP-2), the developmental expression of this water channel was studied in rats. AQP-2 levels were lower during early postnatal life, reaching maximal expression at 10 wk of age. Concurrently, urine osmolality increased from 242 +/- 60 to 1267 +/- 311 mosmol/kg. To study the regulation of AQP-2, immature and adult rats were kept on ad libitum intake or were water-deprived. Under normal conditions, AQP-2 levels in the immature rat were significantly lower (52.3 +/- 5.8%, P < 0.001) than in the adult. However, after dehydration the expression increased to adult levels. Interestingly, the increase in AQP-2 observed in the immature kidney was not accompanied by a proportional increase in urine osmolality. To rule out a potential alteration in AQP-2 trafficking, the transport of this water channel was investigated in a group of rats subjected to dehydration, treated with desmopressin acetate (dDAVP), or water loaded. Dehydration and dDAVP stimulated translocation of AQP-2 from intracellular vesicles to the plasma membrane, whereas water loading caused a shift of AQP-2 channels back to intracellular vesicles in both adult and immature animals. In summary, AQP-2 expression and trafficking in the immature kidney is appropriately stimulated by water deprivation and dDAVP. However, urine osmolality remained significantly decreased. From this study, it is concluded that although AQP-2 expression may play a role in the development of urine concentrating abilities, there still is a significant defect, yet to be defined, distal to AQP-2.

Neonatal presentation of Gordon syndrome.

Gordon syndrome, the association of hypertension with hyperkalemic acidosis, has been described in older children and adults. We report an affected family in which two of the members had exhibited the metabolic manifestations of the disease since infancy. Both patients responded well to thiazides. To our knowledge, these are the youngest patients with documented cases of Gordon syndrome.

Expression and localization of prostaglandin EP3 receptor mRNA in the immature rabbit kidney.

Arginine vasopressin (AVP)-stimulated cAMP generation is decreased in the immature collecting duct (CD). This is the result of prostaglandin antagonism, most likely via the inhibitory guanine nucleotide-binding protein (Gi). The EP3-subtype prostaglandin E2 (PGE2) receptor, which is coupled to Gi, could mediate this effect. We studied the developmental expression of EP3 receptor in the rabbit kidney. Higher levels of EP3 mRNA were observed in the immature kidney using three different assays: 1) reverse transcription-polymerase chain reaction (RT-PCR) with internal standard, 2) competitive PCR, and 3) ribonuclease protection assay. The highest levels were observed at 2 wk of age. RT-PCR from isolated nephron segments detected EP3 mRNA in the medullary thick ascending limb, cortical CD (CCD), and inner medullary CD (IMCD) of adult and immature kidneys. We conclude that 1) renal expression of EP3 mRNA is increased in immature kidneys and 2) EP3 mRNA is localized in the distal nephron. This suggests that EP3 receptor may play a role in the regulation of distal tubular transport during development.

Primary distal renal tubular acidosis as a result of a gradient defect.

It has been generally accepted that primary distal renal tubular acidosis (DRTA) is the result of a defect in proton secretion in the distal nephron (secretory defect). We report an infant with DRTA, evidenced by spontaneous hyperchloremic metabolic acidosis with low urinary ammonium excretion rate and inability to decrease urine pH during acidosis, who nevertheless exhibited an intact ability to increase urinary carbon dioxide partial pressure (pCO2) during maximal urine alkalinization and normal ability to acidify the urine after furosemide, suggestive of a gradient-type defect DRTA. This patient had never been exposed to amphotericin B. To our knowledge, this is the first fully documented report of primary DRTA that can be attributed to gradient defect.

Nephrotic syndrome related to systemic lupus erythematosus after griseofulvin therapy.

We report a 16-year-old male who developed nephrotic syndrome related to membranous glomerulopathy with clinical and serological evidence of systemic lupus erythematosus after treatment with griseofulvin. To our knowledge, this is the first case of griseofulvin-exacerbated lupus in which nephrotic syndrome has been observed.

Prostaglandins mediate the defect in AVP-stimulated cAMP generation in immature collecting duct.

The immature kidney is characterized by resistance to arginine vasopressin (AVP). In the immature cortical collecting duct (iCCD), AVP-stimulated adenosine 3',5'-cyclic monophosphate (cAMP) generation is decreased, but the mechanisms involved are not known. We examined cAMP production in isolated CCD from immature and mature rabbits. Cellular cAMP levels were measured by radioimmunoassay under basal conditions and after stimulation with hormone. Basal cAMP production in the iCCD was not different from that in the mature CCD (mCCD). In contrast, AVP- and forskolin-stimulated cAMP generation were severely decreased in the iCCD. Inhibition of endogenous prostaglandin production by indomethacin increased AVP-stimulated cAMP generation in the iCCD to levels that were not different from the mCCD. Inhibition of protein kinase C (PKC) by staurosporine and inhibition of Gi by pertussis toxin elicited a mature cAMP response in the iCCD. These data suggest that the defect in AVP-stimulated cAMP production in the iCCD is mediated by prostaglandins via 1) activation of Gi and 2) direct inhibition of the adenylyl cyclase catalytic subunit. In addition, PKC appears to play a significant role.

Renal acidification in children with idiopathic hypercalciuria.

Distal renal tubular acidosis is frequently associated with hypercalciuria. To further investigate the cause-and-effect relationships between the two conditions, we examined 20 children (5 to 18 years of age) with idiopathic hypercalciuria for evidence of renal tubular acidosis. Serum electrolytes and urine citrate levels were normal in all subjects. After a single dose of furosemide, 1 of the 20 subjects did not show a decrease in urine pH < 5.5, which suggests an acidification defect in the cortical collecting duct. Three other patients failed to show an increase in urine-minus-blood partial pressure of carbon dioxide > 20 mmHg after urine alkalinization with orally administered acetazolamide, a finding compatible with a rate-dependent distal renal tubular acidosis. These four subjects underwent acute acid loading with arginine hydrochloride. In all four subjects urine pH decreased < 5.5 but urinary ammonium excretion failed to increase normally; this supports the diagnosis of a defect in distal acidification. Four of six patients with nephrolithiasis had evidence of distal renal tubular acidosis, in contrast to none of the 14 patients without stones (p = 0.003). We conclude that distal acidification abilities seem to be intact in children with hypercalciuria in the absence of nephrolithiasis. We speculate that calcium precipitation may lead to tubular damage, including distal renal tubular acidosis.

Response of cortical collecting ducts from remnant kidneys to arginine vasopressin.

Chronic renal failure is associated with impaired urine concentration. Previous studies have demonstrated that cortical collecting ducts (CCD) from uremic rabbits (with remnant kidneys) have an impaired response to arginine vasopressin (AVP). To determine whether this defect is an early, integral component of compensatory renal growth by the remnant kidney, we studied the response of CCD derived from rabbits one week after 75% nephrectomy. At one week, hypertrophy and adaptation in sodium transport are fully developed, but azotemia and interstitial fibrosis are absent. The animals with remnant kidneys failed to respond normally to water deprivation and dDAVP (maximum urine osmolality 738 +/- 29.1 mOsm/kg compared to 1378 +/- 207 in sham operated). However, in isolated, perfused CCD from remnant kidneys, AVP stimulated hydraulic water permeability to the same extent as in normal CCD or CCD from sham operated animals. AVP-induced cAMP generation per mm tubule length was significantly higher in the CCD from remnant kidneys (137.4 +/- 14.5 fmol/mm) than in the control group (82.4 +/- 11.9 fmol/mm), but not different when expressed per micrograms protein. These studies demonstrate that one week after reduction in renal mass there is no defect in the response of CCD to AVP, suggesting that the mechanisms responsible for the hyposthenuria after loss of renal mass are not related to any intrinsic cellular changes that occur in CCD early during compensatory renal growth.