Biotransformation of lovastatin. V. Species differences in in vivo metabolite profiles of mouse, rat, dog, and human.

Lovastatin is a prodrug lactone whose open-chain 3,5-dihydroxy acid is a potent, competitive inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme A reductase, the rate-limiting enzyme in cholesterol biosynthesis. The compound undergoes extensive and complex metabolism in animals and humans, with the metabolites excreted predominantly in bile. Radiochromatograms of bile from three human subjects and of bile and liver homogenates from mouse, rat, and dog displayed obvious species differences. Biotransformation of lovastatin occurred by three distinct routes, namely hydrolysis of the lactone ring to yield the pharmacologically active dihydroxy acid, cytochrome P-450-mediated oxidation of the fused-ring system, and beta-oxidation of the dihydroxy acid side chain. The first two reactions occurred in all four species, but the last was observed in mouse and rat only. The P-450 reactions, hydroxylation and a novel dehydrogenation reaction, yielded a 6'-hydroxylated metabolite of the dihydroxy acid and a 6'-exomethylene derivative as major and minor metabolites, respectively, in the bile of rat and dog. Human bile, which contained predominantly polar metabolites, yielded these metabolites in similar proportions only after mild hydrolysis at pH 5.0. In mouse and rat an atypical beta-oxidation of the dihydroxy acid side chain occurred to give a pentanoic acid derivative that was observed in liver homogenates. This metabolite was subsequently conjugated with taurine and excreted in the bile. From these studies, cytochrome P-450 oxidation is the primary route of phase I metabolism for lovastatin in human and dog, but beta-oxidation plays a major metabolic role in rodents.

Effects of dose, sex, and age on the disposition of alendronate, a potent antiosteolytic bisphosphonate, in rats.

Alendronate (4-amino-1-hydroxybutylidene-1,1-bisphosphonate), an antiosteolytic agent, is currently under investigation in the treatment of a variety of bone disorders. Earlier studies from this laboratory have demonstrated that systemically administered drug was rapidly taken up by bone tissue or excreted by the kidneys. Approximately 60 to 70% of the dose was taken up by the bone, and 30 to 40% was excreted in the urine. The purpose of this study was to determine the effects of dose, sex, and age on the disposition kinetics of alendronate using rats as an animal model. No evidence of saturation of drug uptake by the bone was observed in young rats when small, repetitive doses of alendronate were administered every 3 days for 21 days (total 35 mg/kg iv). However, less than proportional uptake by the bone was observed in young rats when single iv doses exceeded 10 mg/kg. Overall, a 500-fold increase in dose resulted in a 350-fold increase in drug concentration in bone. Nonlinear uptake of alendronate by bone was accompanied by simultaneous accumulation in noncalcified tissues at high doses. Less than 1% of the dose was found in noncalcified tissues at 24 hr after low doses (1 mg/kg iv), and 25% after high doses (30 mg/kg iv). Following iv administration, uptake of alendronate by the bone was lower in senescent rats than in young rats by a factor of 2 to 3. Bone uptake was lower in female rats than in male rats by about 30 to 40%, but this sex difference was only observed at low doses and in young rats.

Physiological disposition of alendronate, a potent anti-osteolytic bisphosphonate, in laboratory animals.

Alendronate (4-amino-1-hydroxybutylidene-1,1-bisphosphonate) is currently under investigation as an anti-osteolytic agent in the treatment of a broad range of bone disorders. This study describes the absorption and disposition of the drug in laboratory animals. Following iv administration, alendronate was rapidly cleared from plasma, either taken up and sequestered in the bone or excreted by the kidney. About 30 to 40% of the dose was excreted in the urine in 24 hr, with most of the drug being excreted in the first 3 to 4 hr. There was little or no accumulation of the drug in noncalcified tissues and only a very small fraction of the dose was excreted in the bile. Most of the dose was rapidly taken up by bone tissues: 30% in 5 min, 60% in 1 hr. Absorption of alendronate was very poor. Based on the ratios in bone of the labels from the 14C-labeled oral dose and the 3H-labeled iv dose, absorption was estimated to be about 0.9% for the rat, 1.8% for the dog, and 1.7% for the monkey. Comparison of the concentrations of alendronate in bones of the same rats in fasted (3H-labeled) and fed (14C-labeled) states indicated that food caused a substantial decrease in absorption, by about 6- to 7-fold. The terminal half-life of alendronate in bone was about 200 days for the rat. Based on urinary excretion, the terminal half-life was estimated to be about 1000 days for the dog. The long persistence of alendronate in bone was likely due to its slow dissolution rate from bone tissues.

High-performance liquid chromatographic determination of cilastatin and its major metabolite N-acetylcilastatin in rat plasma, urine and bile.

A new high-performance liquid chromatographic method coupled with solid-phase (C8) sample extraction has been developed for the simultaneous quantification of cilastatin and its major metabolite N-acetylcilastatin in rat plasma, urine and bile. The method is linear, reproducible and reliable with a detection limit of 1 microgram/ml in all three fluids. Plasma concentrations of cilastatin and N-acetylcilastatin at selected time intervals and biliary and urinary recoveries of cilastatin and N-acetylcilastatin following an intravenous dose of 10 mg/kg cilastatin are presented.

Dose-dependent pharmacokinetics of MK-417, a potent carbonic anhydrase inhibitor, in rabbits following single and multiple doses.

MK-417, a potent carbonic anhydrase inhibitor capable of reducing intraocular pressure after topical application, is currently under investigation for the treatment of glaucoma. The purposes of this study were to characterize dose-dependent pharmacokinetics of MK-417 and to determine the accumulating effect of the drug during chronic topical administration in rabbits. Because the drug resided primarily in the erythrocytes, kinetic analyses were performed on whole blood concentration data. Following i.v. administration, both total blood clearance and apparent volume of distribution for MK-417 increased disproportionately between the low and high dose, while the half-life of the drug appeared to be independent of dose. Total blood clearance and apparent volume of distribution increased from 0.993 +/- 0.224 ml/hr/kg (mean +/- SD) and 88.6 +/- 9.4 ml/kg at a dose of 0.05 mg/kg to 2.73 +/- 0.17 ml/hr/kg and 272 +/- 5.5 ml/kg at a dose of 1 mg/kg. The dose-dependent kinetics of MK-417 are probably due to the saturable binding of carbonic anhydrase. Upon instillation of MK-417 into the eyes, the drug was rapidly and well absorbed. At the low dose of 0.05 mg/kg, the bioavailability varied from 58% to 98.5% with a mean value of 76.5 +/- 20.5%. Prediction of concentrations of MK-417 during chronic topical administration were performed based on the corresponding concentrations after a single topical dose using an overlay technique. Good agreement between the experimental data and the predicted blood concentrations of MK-417 during chronic dosing at 0.05 mg/kg, but not at 1 mg/kg, strongly suggests that linear kinetics apply in the case of the low dose but not in the case of the high dose.

In vitro and in vivo biotransformation of simvastatin, an inhibitor of HMG CoA reductase.

Simvastatin (SV), an analog of lovastatin, is the lactone form of 1', 2', 6', 7', 8', 8a'-hexahydro-3,5-dihydroxy-2', 6'-dimethyl-8' (2", 2"-dimethyl-1"-oxobutoxy)-1'-naphthalene-heptanoic acid (SVA) which lowers plasma cholesterol by inhibiting 3-hydroxy-3-methylglutaryl-CoA reductase. SV but not its corresponding hydroxy acid form SVA underwent microsomal metabolism. Major in vitro metabolites were 6'-OH-SV (I) and 3"-OH-SV (III) formed by allylic and aliphatic hydroxylation, respectively, and 6'-exomethylene-SV (IV) formed by dehydrogenation. In rats, dogs, and humans, biliary excretion is the major route of elimination. Biliary metabolites (as both hydroxy acids and lactones) also included 6'-CH2OH-SV (V) and 6'-COOH-SV (VI) in both of which the 6'-chiral center had been inverted. High levels of esterase in rodent plasma favored the formation of SVA from SV. The formation of 1', 2', 6', 7', 8', 8a'-hexahydro-2', 6'-dimethyl-8'-(2",2"-dimethyl-1-oxobutoxy)-1'-naphthalene-pentano ic acid (VII) only in rodents represented a species difference in the metabolism of SV. It is proposed that VII is formed by beta-oxidation pathways of fatty acid intermediary metabolism. Several metabolites resulting from microsomal oxidation (after subsequent conversion from lactones to hydroxy acids) are effective inhibitors of 3-hydroxy-3-methylglutaryl-CoA reductase and may contribute to the cholesterol lowering effect of SV. Qualitatively, the metabolism of SV closely resembles that of lovastatin.

Metabolic disposition studies on simvastatin, a cholesterol-lowering prodrug.

The biosynthesis of cholesterol is mainly regulated by 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase. Because the liver is the major site of cholesterol synthesis, it is the primary target of the class of drugs known as HMG-CoA reductase inhibitors. Simvastatin (SV) is a lactone prodrug which undergoes reversible metabolism. In the hydroxy acid form (SVA) it is a potent inhibitor of HMG-CoA reductase. SV is well absorbed by rats, dogs, and humans. After an oral dose of SV, tissue distribution studies were consistent with high hepatic extraction of SV and relatively poor tissue penetration of SVA. The majority of a radioactive dose of SV is eliminated in bile. A high portal/systemic gradient for 6'-OH-SVA, an active biliary metabolite, suggests its probable reentry and indicates potential for prolongation of HMG-CoA reductase inhibition. AUC comparisons in dogs after simultaneous iv (3H) and intraportal (14C) infusions indicate that hepatic extraction is high with only 8% of SV reaching the systemic circulation unchanged. Approximately 98% and 96% of SV was bound to human and dog plasma protein, respectively. The physiological disposition of SV in dog appears to be a suitable paradigm for man. Because of its high hepatic extraction SV should be both specific and selective with respect to the inhibition of HMG-CoA reductase.

Biotransformation of lovastatin. II. In vitro metabolism by rat and mouse liver microsomes and involvement of cytochrome P-450 in dehydrogenation of lovastatin.

Metabolism of lovastatin, a new cholesterol-lowering drug, by liver microsomes from rats and mice was investigated. Liver microsomes from rats catalyzed biotransformation of lovastatin at a rate of 3 nmol/mg of protein/min, whereas the rate of metabolism was 37% higher with liver microsomes from mice. The profiles of metabolites were similar, but the relative abundance of individual metabolites was species dependent. Hydroxylation at the 6'-position was the principal pathway of lovastatin biotransformation, whereas hydroxylation at the 3"-position of the side chain was a minor pathway. In both species the 6'-beta-hydroxy-lovastatin accounted for half of the total metabolism. Liver microsomes from rats produced 2- to 4-fold higher amounts of the other three metabolites, namely, 6'-exomethylene-, 3"-hydroxy-, and the hydroxy acid form, than mouse liver microsomes. The conversion of lovastatin to the novel 6'-exomethylene metabolite was catalyzed by cytochrome P-450 since it required microsomes and NADPH and was inhibited by SKF-525A, metyrapone, and 2,4,-dichloro-6-phenylphenoxyethylamine (DPEA). Furthermore, neither 6'-beta-hydroxy-lovastatin nor the 6'-hydroxymethyl analogs could be demonstrated to be intermediates in the formation of the 6'-exomethylene metabolite. The hydroxy acid form of lovastatin was not a substrate for liver microsomes from either species.

The physiological disposition of lovastatin.

Lovastatin is a pro-drug lactone whose open chain beta-hydroxy-acid (HA) is a potent inhibitor of hydroxymethylglutaryl-CoA-reductase and thus of cholesterol synthesis. Because the liver is the major site of cholesterolgenesis, it is the principal target organ for agents of this class. In animals, lovastatin is not as well absorbed as HA given per se, but that fraction that is absorbed reaches the portal circulation largely unchanged and is more efficiently extracted by the liver, after which it is reversibly biotransformed to HA and irreversibly to other enzymatically active products. These, like HA, maintain high hepatic gradients relative to all tissues examined. The minimal systemic burden for HA is attributable in part to the metabolic equilibrium, lovastatin in equilibrium HA, the opposing reactions for which appear to be present in most tissues. Excretion is very largely biliary in all species. Detailed comparisons of absorption, distribution, metabolism, and excretion profiles presented here and elsewhere indicate dogs to be the most appropriate paradigm for humans for study of lovastatin disposition.

Differential renal handling of angiotensin-converting enzyme inhibitors enalaprilat and lisinopril in rats.

Enalaprilat, the active metabolite of enalapril, and its lysine analogue lisinopril are potent nonsulfhydryl angiotensin-converting enzyme inhibitors. Earlier studies from our laboratories demonstrated that neither drug is significantly metabolized, and both are almost exclusively eliminated by renal excretion. This report compares the renal excretory mechanisms for these structurally related compounds in the rat. After an iv, 1-mg/kg dose, ratios of renal clearance (CLR) of unbound drug to glomerular filtration rate (GFR) for enalaprilat and lisinopril were 2.72 +/- 0.70 and 1.01 +/- 0.18, respectively, suggesting that enalaprilat, but not lisinopril, was actively secreted by the kidneys. Treatment with probenecid and p-aminohippuric acid, potent competitive inhibitors for the renal anionic transport system, caused a profound decrease in the renal clearance of enalaprilat to the level of GFR. The CLR/fu.GFR, where fu is the unbound fraction, became 1.10 +/- 0.09 and 1.25 +/- 0.25, respectively. These results and the fact that quinine, a potent inhibitor for the cationic transport system, had little effect on the renal clearance of enalaprilat indicated that enalaprilat is secreted by the organic anion transport system. On the other hand, probenecid, p-aminohippuric acid, and quinine had no effect on the renal clearance of lisinopril, suggesting that lisinopril is eliminated exclusively by glomerular filtration.

Kinetic studies on the competition between famotidine and cimetidine in rats. Evidence of multiple renal secretory systems for organic cations.

The H2-receptor antagonists famotidine and cimetidine are both basic drugs that are predominantly eliminated by the kidneys. Cimetidine has been shown to inhibit the renal secretion of tetraethyl-ammonium bromide (TEAB) but not p-aminohippuric acid (PAH), suggesting that cimetidine is secreted by an organic cation transport system [Weiner and Roth: J. Pharmacol. Exp. Ther. 216: 516 (1981)]. The present study shows that famotidine behaves like cimetidine in that it also inhibits TEAB but not PAH excretion. Where a high concentration of cimetidine in plasma has an inhibitory effect on the renal excretion of famotidine, the reverse is not true, i.e. high plasma levels of famotidine have no effect on the excretion of cimetidine. Further evidence that additional transport systems are involved in the renal tubular secretion of cimetidine is as follows. Quinine, a potent competitor of the organic cation transport system, inhibits the secretory component of famotidine renal clearance but not that of cimetidine. Probenecid, a classic competitor for the organic anion transport system, inhibits the renal excretion of cimetidine but not famotidine. However, the effect of probenecid is minor and not sufficient to account for other components of cimetidine secretion not affected by famotidine and quinine.

Differential effects of phenobarbital on ester and ether glucuronidation of diflunisal in rats.

The relative contribution of ether and ester glucuronidation to diflunisal metabolism was assessed by studying the effects of enzyme inducers, phenobarbital (PB), 3-methylcholanthrene (3-MC) and beta-naphthoflavone (BNF). Treatment with either PB, 3-MC or BNF increased markedly the unbound intrinsic clearance of diflunisal. Saline-treated control rats showed a greater unbound intrinsic clearance of diflunisal than oil-treated controls indicating that repetitive treatment with oil had an effect on enzyme activity. Treatment with 3-MC and BNF appeared to cause a decrease in the biliary clearance of ether and ester glucuronide, but PB had little effect on the biliary clearance of glucuronides. Rats pretreated with PB showed a 3-fold increase in the fractional metabolite formation clearance of ether glucuronide and a 2-fold increase in the fractional metabolite formation clearance of ester glucuronide, suggesting differential effects of PB on ester and ether glucuronidation. A similar trend, but to a smaller extent, was also observed for 3-MC- and BNF-treated rats. These results suggest the possibility of selective induction of multiple forms of UDP-glucuronyltransferase involved in metabolism of diflunisal.

Protein binding as a primary determinant of the clinical pharmacokinetic properties of non-steroidal anti-inflammatory drugs.

The ability of a wide variety of anionic, cationic, and neutral drugs to bind in a reversible manner to plasma proteins has long been recognised. Non-steroidal anti-inflammatory drugs (NSAIDs) are distinguished as a class by the high degree to which they bind to plasma protein. Plasma protein binding properties are primary determinants of the pharmacokinetic properties of the NSAIDs. Theoretical relationships are reviewed in order to define quantitatively the impact of plasma protein binding on clearance, half-life, apparent volume of distribution, and the duration and intensity of pharmacological effect. The quantitative relationships governing competitive displacement binding interactions are also presented. Experimental methods for in vitro and in vivo determination of the degree of plasma protein binding are discussed. The more common in vitro methods are equilibrium dialysis and ultrafiltration. Methods for characterising the degree of plasma protein binding in vivo consist of either measuring the concentration of drug at equilibrium in an implanted semipermeable vessel or measuring the relative drug concentrations in two body spaces with different protein content. Emphasis is given to the comparative advantages and disadvantages of experimental application of the various in vitro and in vivo methods. Plasma protein binding is discussed as a determinant of the trans-synovial transport of NSAIDs. Trans-synovial transport of NSAIDs appears to be a diffusional process. Limited data in humans receiving ibuprofen, indomethacin, aspirin, carprofen, alclofenac, or diclofenac suggest that clearance of each of these NSAIDs from the synovium is slower than clearance from plasma. The clinical data relevant to the relationship between plasma NSAID concentration and various measures of anti-inflammatory effect are reviewed. A positive correlation between plasma NSAID concentration and anti-inflammatory effect has been observed in only one study on naproxen and one study on piroxicam. In several other studies, the lack of concentration-response correlations is generally attributed to the relatively subjective, quantitatively inexact methods used to assess anti-inflammatory effect and analgesia in arthritic patients, as well as the substantial interpatient variabilities in the fraction of unbound NSAID and the unbound plasma NSAID concentration. In view of the generally poor correlation between concentration and therapeutic response, routine therapeutic monitoring of total plasma NSAID concentration is not recommended as a means of titrating individual dosages to the desired effect in each patient.(ABSTRACT TRUNCATED AT 400 WORDS)

Urinary excretion kinetics of famotidine in rats.

Famotidine is a new histamine H2-receptor antagonist which has been demonstrated to be more potent than cimetidine and ranitidine in inhibiting gastric acid secretion. Nine groups of adult male Sprague-Dawley rats received an ia injection of various loading doses of famotidine followed immediately by a constant infusion of the drug at different rates for 6 hr. When steady state famotidine concentrations in plasma were low, renal clearance of the drug (CLR) was greater than glomerular filtration (GFR), and the ratio CLR/GFR was about 4.5 at plasma concentrations of 0.2-1.8 micrograms/ml, suggesting that famotidine was actively secreted by the renal tubules. The CLR decreased as famotidine concentration in plasma increased, and the ratio CLR/GFR approached 1 in the concentration range of 25-76 micrograms/ml, thus providing evidence for saturation of the secretory mechanism. The maximum rate of secretory transport (Tm) of famotidine averaged 180 micrograms/min/kg. On average, some 50-70% of an ia bolus dose was excreted in the urine as unchanged drug within 24 hr of administration. Over the dose range of 0.3-30 mg/kg famotidine, there was no dose-dependent effect on total or renal clearance. Since the lowest dose level, 0.3 mg/kg, is below the recommended human therapeutic dose for famotidine (0.6 mg/kg), the saturation of the renal excretion process observed here in rats is not likely to be of clinical significance.

Comparative effects of H2-receptor antagonists on drug interaction in rats.

The most widely used H2-receptor antagonist, cimetidine, is known to interact with cytochrome P-450 drug-metabolizing enzymes and, therefore, interacts with other drugs which may be administered concurrently. In this study, effects of three H2-receptor antagonists, famotidine, ranitidine, and L-643,441, on drug interaction were studied using cimetidine as a positive control. Cimetidine and L-643,441, but not famotidine or ranitidine, prolonged antipyrine elimination and hexobarbital-induced sleeping time. The effect of cimetidine and famotidine on the anticoagulant effect on warfarin in rats was also investigated. Pretreatment of rats with cimetidine produced a significant depression of plasma prothrombin complex activity, whereas concomitant administration of famotidine did not alter the plasma prothrombin complex activity. Whereas cimetidine is known to impair the elimination of a number of drugs metabolized by microsomal mixed function oxidase enzyme systems, the results of the present study suggest that famotidine and ranitidine have little effect on these enzyme systems.

Possible mechanisms for reduced plasma clearance of diflunisal in rat experimental renal failure.

To provide insight into the reported reduction in the plasma clearance of diflunisal in human renal failure, this investigation evaluated several possible mechanisms for this effect in experimental renal failure. Rats with renal failure, induced by uranyl nitrate or by ureteral ligation, had both a lower plasma clearance and an increased apparent volume of distribution, a pattern resembling that seen in human renal failure. Steady-state diflunisal concentration and unbound fraction were determined in studies during a constant infusion of diflunisal to establish the relationships of concentration, protein binding and intrinsic clearance. The infusion studies revealed that the intrinsic clearance of diflunisal, i.e., the ability of enzyme system(s) to metabolize the drug, was decreased in uremia. Also, plasma protein binding of diflunisal was decreased, which may explain the increase in apparent volume of distribution in uremic rats. The decreased intrinsic clearance of diflunisal in uremic rats may be due partly to saturation of biotransformation process(es) by increasing unbound concentration as a consequence of impairment of plasma protein binding of diflunisal, and partly due to the diminished enzyme activity of glucuronidation by renal failure. The lack of an effect of the esterase inhibitor phenylmethylsulfonyl fluoride on the intrinsic clearance of diflunisal in uremic rats suggested that the reduced intrinsic clearance of diflunisal was not attributable to the systemic enzymatic hydrolysis of the ester glucuronide.

Dose-dependent pharmacokinetics of diflunisal in rats: dual effects of protein binding and metabolism.

The purpose of this study was to define the dual effects of saturable metabolism and saturable protein binding on the pharmacokinetics of diflunisal. Steady-state diflunisal concentration and its unbound fraction were examined in seven groups of rats to determine the relationships of infusion rate, concentration and total and unbound clearances. The total body plasma clearance decreased initially and then went up as the concentration of diflunisal increased, whereas the intrinsic clearance of unbound drug decreased with increasing concentration. The former is a consequence of saturable metabolism as well as saturable protein binding; the latter is a consequence of saturable metabolism. The fraction of unbound diflunisal increased with concentration. The biliary excretion data of ester and ether glucuronide suggested that both the ester and ether glucuronidation processes are capacity-limited, although the enzyme system for ether glucuronide has a lower Km and capacity than the system responsible for the ester glucuronidation.

Effect of uremia and anephric state on the pharmacokinetics of sulindac and its metabolites in rats. I. An application of pharmacokinetic model for reversible metabolism.

Plasma levels of sulindac and its metabolites, sulfide and sulfone, were measured in normal, uremic, and anephric rats following concurrent administration of 11C-sulindac and 3H-sulfide (5 mg-eq/kg). A marked decrease in plasma concentration of sulfide was found in uremic rats, while sulindac concentration in these rats was unchanged. In contrast, anephric rats cleared sulindac more slowly than control rats, but had no effect on the sulfide. A pharmacokinetic model for reversible metabolism was used to characterize the kinetic parameters for sulindac----sulfide interconversion system. The intrinsic clearances of unbound drug were calculated for the interconversion and elimination processes. The results indicated that the reduction of sulindac to sulfide is impaired in uremic and anephric rats. The oxidation of sulfide to sulindac was increased in uremic rats, but decreased in anephric rats. Experimental uremia caused a decrease in plasma protein binding of sulindac and sulfide and an increase in the apparent volumes of distribution of the redox species. Anephric state has less effect on plasma protein binding and volume distribution.

Effect of uremia and anephric state on the pharmacokinetics of sulindac and its metabolites in rats. II. Differential effects on the biliary excretion.

The differential effects of experimental uremia and surgical anephric state on the biliary excretion of sulindac and its metabolites in rats were investigated. After concurrent administration of 14C-sulindac and 3H-sulfide (5 mg-eq/kg iv), the apparent biliary clearance of sulindac was significantly decreased in anephric rats relative to control rats, whereas the apparent biliary clearance of sulfide was increased in uremic rats as compared to that in control rats. There was a strong positive correlation between the irreversible elimination of sulindac (CLox) and the apparent biliary clearance (r = 0.942). Similarly, the irreversible elimination of sulfide (CLide) was positively correlated with the apparent biliary clearance of sulfide (r = 0.961). A partial explanation is thus provided for differences in the respective effects of uremic and anephric state upon observed CLox and CLide.