Ryanodine receptor and capacitative Ca2+ entry in fresh preglomerular vascular smooth muscle cells.

BACKGROUND: A multiplicity of hormonal, neural, and paracrine factors regulates preglomerular arterial tone by stimulating calcium entry or mobilization. We have previously provided evidence for capacitative (store-operated) Ca2+ entry in fresh renal vascular smooth muscle cells (VSMCs). Ryanodine-sensitive receptors (RyRs) have recently been identified in a variety of nonrenal vascular beds. METHODS: We isolated fresh rat preglomerular VSMCs with a magnetized microsphere/sieving technique; cytosolic Ca2+ ([Ca2+]i) was measured with fura-2 ratiometric fluorescence. RESULTS: Ryanodine (3 micromol/L) increased [Ca2+]i from 79 to 138 nmol/L (P = 0.01). Nifedipine (Nif), given before or after ryanodine, was without effect. The addition of calcium (1 mmol/L) to VSMCs in calcium-free buffer did not alter resting [Ca2+]i. In Ca-free buffer containing Nif, [Ca2+]i rose from 61 to 88 nmol/L after the addition of the Ca2+-ATPase inhibitor cyclopiazonic acid and to 159 nmol/L after the addition of Ca2+ (1 mmol/L). Mn2+ quenched the Ca/fura signal, confirming divalent cation entry. In Ca-free buffer with Nif, [Ca2+]i increased from 80 to 94 nmol/L with the addition of ryanodine and further to 166 nmol/L after the addition of Ca2+ (1 mmol/L). Mn2+ quenching was again shown. Thus, emptying of the sarcoplasmic reticulum (SR) with ryanodine stimulated capacitative Ca2+ entry. CONCLUSION: Preglomerular VSMCs have functional RyR, and a capacitative (store-operated) entry mechanism is activated by the depletion of SR Ca2+ with ryanodine, as is the case with inhibitors of SR Ca2+-ATPase.

Capacitative calcium entry in smooth muscle cells from preglomerular vessels.

Calcium entry via voltage-gated L-type channels is responsible for at least half of the increase in cytosolic calcium ([Ca(2+)](i)) in afferent arterioles following agonist stimulation. We sought the presence of capacitative calcium entry in fresh vascular smooth muscle cells (VSMC) derived from rat preglomerular vessels. [Ca(2+)](i) was measured using fura-2 ratiometric fluorescence. Vasopressin V1 receptor agonist (V1R) (10(-7) M) increased [Ca(2+)](i) by approximately 100 nM. A calcium channel blocker (CCB), nifedipine or verapamil (10(-7) M), inhibited the response by approximately 50%. V1R in the presence of CCB increased [Ca(2+)](i) from 106 to 176 nM, confirming that calcium mobilization and/or entry may occur independent of voltage-gated channels. In nominally Ca(2+)-free buffer, V1R increased [Ca(2+)](i) from 94 to 129 nM, denoting mobilization; addition of CaCl(2) (1 mM) further elevated [Ca(2+)](i) to 176 nM, indicating a secondary phase of Ca(2+) entry. Similar responses were obtained when CCB was present in calcium-free buffer or when EGTA was present. In nominally Ca(2+)-free medium, the sarcoplasmic reticulum Ca(2+)-ATPase inhibitors (SRCAI), thapsigargin and cyclopiazonic acid (CPA), increased [Ca(2+)](i) from 97 to 128 and 143 nM, respectively, and to 214 and 220 nM, respectively, when 1 mM extracellular Ca(2+) was added. In the presence of verapamil, the results with CPA acid were nearly identical. In Ca(2+)-free buffer, the stimulatory effect of V1R or SRCAI on the Ca(2+)/fura signal was quenched by the addition of Mn(2+) (1 mM), demonstrating divalent cation entry. These studies provide evidence for capacitative (store- operated) calcium entry in VSMC freshly isolated from rat preglomerular arterioles.

Disparate effects of three types of extracellular acidosis on left ventricular function.

Effects of acidosis on muscle contractile function have been studied extensively. However, the relative effects of different types of extracellular acidosis on left ventricular (LV) contractile function, especially the temporal features of contraction, have not been investigated in a single model. We constituted perfusion buffers of identical ionic composition, including Ca2+ concentration ([Ca2+]), to mimic physiological control condition (pH 7.40) and three types of acidosis with pH of 7.03: inorganic (IA), respiratory (RA), and lactic (LA). Isolated rabbit hearts (n = 9) were perfused with acidotic buffers chosen at random, each preceded by the control buffer. Under steady-state conditions, instantaneous LV pressure (Pv) and volume (Vv) were recorded for a range of Vv. The results were as follows. 1) LV passive (end-diastolic) elastance increased with IA and RA. However, this increase may not be a direct effect of acidosis; it can be explained on the basis of myocardial turgor. 2) Although LV inotropic state (peak active Pv and elastance) was depressed by all three acidotic buffers, the magnitude of inotropic depression was significantly less for LA. 3) Temporal features of Pv were altered differently. Whereas IA and RA reduced time to peak Pv (tmax) and hastened isovolumic relaxation at a common level of LV wall stress, LA significantly increased tmax and retarded relaxation. These results and a model-based interpretation suggest that cooperative feedback (i.e., force-activation interaction) plays an important role in acidosis-induced changes in LV contractile function. Furthermore, it is proposed that LA-induced responses comprise two components, one due to intracellular acidosis and the other due to pH-independent effects of lactate ions.

History of the science of dialysis.

Thomas Graham (1805-1869), who is credited with seminal work on the nature of the diffusion of gases and of osmotic forces in fluids, can properly be called the father of modern dialysis. His apparatus to study the behavior of biological fluids through a semipermeable membrane clearly presaged the artificial kidney in clinical use today. In 1913, John Abel and coworkers reported the first application of the principles of diffusion to remove substances from the blood of living animals. Unaware of Abel's work, Georg Haas (1886-1971) performed the first human dialysis in the German town of Giessen in 1924. But it was not until 1945 that Willem Johan Kolff, working under extremely difficult wartime conditions in The Netherlands, achieved the first clinically successful hemodialysis in a human patient.

Ischemic heart disease in patients with end-stage renal disease.

Prevention and treatment of cardiovascular disease and, in particular, ischemic heart disease (IHD) in an increasingly elderly and diabetic population of patients with end-stage renal disease (ESRD) pose a challenge to all members of the renal failure treatment program. The patient described herein presents such a challenge, illustrating risk factors for IHD, the dilemma of performing surgery given his age and comorbid conditions, and the impact of IHD on his quality of life and capacity to function independently. The coordinated efforts of the nephrologist, cardiologist, cardiac surgeon, rehabilitation specialist, nutritionist, primary nurse, and social worker all contributed to a successful intervention.

An outbreak of fatal fluoride intoxication in a long-term hemodialysis unit.

OBJECTIVE: To determine the cause of an outbreak of acute illness and death in a long-term hemodialysis unit. DESIGN: A retrospective cohort and case-control study of patients receiving hemodialysis and a laboratory study of a model deionization system to purify water for hemodialysis. SETTING: An outpatient hemodialysis unit of a university hospital. PATIENTS: 12 patients who became severely ill after hemodialysis treatment and 20 patients who did not become ill after receiving hemodialysis treatment in the same unit. MEASUREMENTS: Medical and dialysis unit records were reviewed to identify and characterize cases. Fluids for dialysis were tested for toxic substances, and fluoride was measured in patients' serum. Resistivity and fluoride were measured in effluent from a model deionization system operated in the same way as the system associated with illness. RESULTS: During five consecutive hemodialysis shifts, 12 of 15 patients receiving dialysis treatment in one room became acutely ill, with severe pruritus, multiple nonspecific symptoms, and/or fatal ventricular fibrillation (3 patients). None of 17 patients treated in the adjacent room became ill (P < 0.0001). Death was associated with longer hemodialysis time and increased age compared with other patients who became ill. Serum concentrations of fluoride in the sick patients were markedly increased to as high as 716 mumol/L, and the source of fluoride was the temporary deionization system used to purify water for hemodialysis only in the affected room. Operation of a model deionization system showed how fluoride was adsorbed and then displaced in a massive efflux. CONCLUSIONS: Because deionization systems are used widely in hemodialysis and can cause fatal fluoride intoxication, careful design and monitoring are essential.

Laparoscopic bilateral nephrectomy for renin-mediated hypertension.

Hypertension arising from retained native kidneys complicates the management of recipients of renal transplants. Reluctance to administer angiotensin-converting enzyme inhibitor (ACEI) drugs to patients taking cyclosporine has reopened the question of performing native nephrectomies for poorly controlled, renin-dependent hypertension. We report the first published cases of simultaneous bilateral laparoscopic nephrectomies in 2 patients: 1 in preparation for living-related donor transplantation and the other ten months following cadaver transplantation in a patient whose end-stage renal disease was from malignant nephrosclerosis. Both had very severe hypertension resistant to multiple drugs and both became normotensive with little or no antihypertensive medication following nephrectomies. A bilateral nephrectomy is currently feasible using a laparoscopic approach.

IgA nephropathy in three successive renal allografts: presumed recurrence of original disease.

We report a patient with presumed recurrence of IgA nephropathy in three successive cadaver transplants. Failure to recognize the cause of progressive renal failure in the first two transplants may have been associated with less than optimal treatment for his hypertension and nephrotic syndrome. His course illustrates the importance of biopsy-documented diagnosis of progressive dysfunction in kidney transplants.

Effect of renal transplantation on serum oxalate and urinary oxalate excretion.

Serum levels of oxalate are elevated in uremic patients on dialysis. The effect of living related donor kidney transplants on serum and urine oxalate levels was studied in 8 patients. Serum and urine oxalate levels were measured prior to transplant, on the day of transplant and daily for 5 days postoperatively, and the results compared to those in 11 normal subjects. All transplanted kidneys functioned immediately. Serum oxalate fell from 55 +/- 9 mumol/l (484 +/- 79 micrograms/dl) before transplant to 21 +/- 3 mumol/l (185 +/- 26 micrograms/dl) the day after transplant, and to 9 +/- 2 mumol/l (79 +/- 18 micrograms/dl) 72 h after transplant. Serum oxalate in normal subjects was 9 +/- 2 mumol/l (79 +/- 18 micrograms/dl). During the initial 24 h after transplant urine oxalate averaged 1,244 +/- 150 mumol/l (109.5 +/- 13.2 mg), but fell to levels not statistically different from normal by 72 h after transplant. Rapid clearance of oxalate after transplant leads to transient hyperoxaluria until normal levels of serum oxalate are reached.

Cardiovascular consequences of correction of the anemia of renal failure with erythropoietin.

The purpose of this study was to define the physiologic responses of the heart and peripheral circulation to chronic anemia using noninvasive measurements while eliminating confounding biochemical, pharmacologic and physiologic variables. Stable chronic hemodialysis patients were studied at the University Hospital based chronic dialysis unit and echocardiography laboratory before and after therapy with human recombinant erythropoietin (rHuEPO). Subjects included maintenance hemodialysis patients free of left ventricular regional wall motion abnormalities discernible by echocardiography, rhythm disturbance, significant valvular or ischemic heart disease. Two-dimensional echocardiograms and simultaneous targeted M-mode echocardiograms, phonocardiograms and externally acquired subclavian artery pulse tracings were used to measure whole blood viscosity, arterial blood gases and ionized calcium, complete blood count, electrolytes, creatinine, blood urea nitrogen (BUN), and inorganic phosphate. All measurements were made immediately post-dialysis before and after therapy with rHuEPO. The interval between pre- and post-rHuEPO studies was 8.3 +/- 2.3 months. We found that post-dialysis hematocrit rose from 24.7 +/- 0.9 to 36.4 +/- 0.9%, hemoglobin from 83 +/- 3 to 121 +/- 3 g/liter and whole blood viscosity from 2.87 +/- 0.11 to 3.71 +/- 0.18 centipoise (all, P < 0.001 after therapy with rHuEPO). The remaining biochemical measurements did not change. Heart rate fell from 83 +/- 3 to 77 +/- 3 beats/min (P = 0.013). Left ventricular preload and afterload were not statistically different before and after rHuEPO. Total vascular resistance rose from 1313 +/- 84 to 1568 +/- 129 dynes.sec.cm-5, P = 0.029. Cardiac output and cardiac index fell by 12 and 15% (P = 0.024 and 0.030), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Improved lipid profiles in patients undergoing high-flux hemodialysis.

Hyperlipidemia is one of many atherogenic risk factors encountered by patients undergoing chronic hemodialysis (HD). We have studied lipid profiles in these patients and have found less hypertriglyceridemia in those undergoing high-flux HD than those receiving traditional HD. Mean +/- SEM triglyceride level was 1.62 +/- 0.15 mmol/L (143.3 +/- 13.6 mg/dL) in high-flux dialysis patients, 2.39 +/- 0.27 mmol/L (211.6 +/- 24.1 mg/dL) in conventional dialysis patients, and 1.55 +/- 0.13 mmol/L (137.1 +/- 11.5 mg/dL) in normal age- and sex-matched controls. In addition, we found that in patients undergoing high-flux HD, females had higher high-density lipoprotein2 (HDL2) levels (0.62 +/- 0.03 mmol/L [23.8 +/- 1.3 mg/dL]) than males (0.33 +/- 0.04 mmol/L [12.9 +/- 1.7 mg/dL]) (P < 0.01). The mechanism(s) responsible for divergent lipid profiles in subsets of HD patients deserves further investigation. Whether reductions of hypertriglyceridemia and/or increases of HDL2 will diminish the incidence of cardiovascular disease in dialysis patients is unknown.

Parathyroid hormone and myocardial performance in dialysis patients.

Whether parathyroid hormone (PTH) has a clinically important effect on myocardial performance is unclear. Previous investigations of cardiac function before and after parathyroidectomy have failed to control for ionized calcium, other biochemical parameters, or heart rate and cardiovascular loading conditions. We performed load- and rate-independent measurements of myocardial contractility in seven stable hemodialysis patients before and after surgical parathyroidectomy under identical conditions of blood ionized calcium (Ca2+), electrolytes, pH, PO2, and hematocrit. Mid-molecule PTH decreased from 44 +/- 8 to 2 +/- 1 ng/mL. Aortic systolic and diastolic pressures, left ventricular chamber dimensions, end systolic wall stress, left ventricular contractility at a common level of afterload, and contractile reserve evaluated with dobutamine were similar before and after parathyroidectomy. Thus, PTH appears not to have a direct effect on myocardial contractile state in dialysis patients.

Elevated lipoprotein(a) levels in renal transplantation and hemodialysis patients.

Hyperlipidemia poses a risk for cardiovascular disease in both hemodialysis and renal transplantation patients. Although lipid profiles differ between the 2 populations, we evaluated the possibility that both groups have similar abnormalities of lipoprotein(a) [Lp(a)]. Mean serum Lp(a) and standard error of the mean (SEM) in hemodialysis and transplant recipients was 16.6 +/- 4.7 and 18.3 +/- 3.6 mg/dl, respectively, compared with 10.7 +/- 4.1 mg/dl in healthy controls, p less than 0.05. That serum Lp(a) levels are significantly elevated in dialysis and renal transplantation patients suggests at least 1 common pathogenic mechanism for the high incidence of atherosclerosis in both groups.

Physiological mechanisms for calcium-induced changes in systemic arterial pressure in stable dialysis patients.

The mechanisms by which variations in blood ionized calcium (Ca2+) influence systemic arterial pressures independent of changes in extracellular fluid volume, pH, and electrolytes are unknown. To study this issue, we dialyzed eight stable hemodialysis patients on three separate occasions during 1 week with dialysates differing only in calcium concentration. Ultrafiltration was adjusted to achieve the patient's estimated dry weight. Postdialysis Ca2+ was measured, as were arterial blood gases, electrolytes, magnesium, blood urea nitrogen, creatinine, and hematocrit. Blood pressures and two-dimensional, targeted M-mode echocardiograms were recorded with the patient in the supine position after 15 minutes of rest. Postdialysis, three different levels of Ca2+ were achieved. Other measured biochemical variables and body weight did not differ among the three study periods. Changes in Ca2+ correlated directly with changes in systolic, diastolic, and mean blood pressures, left ventricular stroke volume, and cardiac output. In contrast, heart rate, left ventricular end-diastolic dimension, and total systemic vascular resistance were not altered significantly by changes in Ca2+. Thus, alterations in Ca2+ within the physiological range affect systemic blood pressure primarily through changes in left ventricular output rather than in peripheral vascular tone in stable dialysis patients.

Left ventricular contractility varies directly with blood ionized calcium.

STUDY OBJECTIVE: To determine the effect of variations in blood ionized calcium (Ca2+) on myocardial contractility independent of changes in loading conditions and other biochemical variables. DESIGN: Hemodialysis done in a randomized, double-blind manner with dialysates differing in calcium concentration only. Left ventricular contractility was assessed using the load- and heart rate-independent relationship between end-systolic wall stress (sigma es) and rate-corrected velocity of fiber shortening (Vcfc). SETTING: In-hospital dialysis unit and echocardiography laboratory of a university medical center. PATIENTS: Seven patients with stable, chronic renal failure maintained on regular hemodialysis. INTERVENTIONS: Each patient was hemodialyzed three times within 1 week with dialysates differing in calcium concentration only. Ultrafiltration was adjusted to achieve the same postdialysis weight. Immediately after dialysis, two-dimensionally targeted M-mode echocardiographic and calibrated carotid pulse tracings were recorded over a wide range of left ventricular end-systolic wall stress values (a measure of left ventricular afterload) generated by either methoxamine or nitroprusside. MEASUREMENTS AND MAIN RESULTS: After dialysis, three statistically distinct levels of Ca2+ were achieved. When Ca2+ was 1.34 +/- 0.03 mmol/L, Vcfc, calculated at a common level of afterload (sigma es = 50 g/cm2), was 1.01 +/- 0.05 cir/sec; at low Ca2+ (1.02 +/- 0.02 mmol/L), Vcfc fell to 0.89 +/- 0.04 cir/sec (P less than 0.001 compared with medium); at high Ca2+ (1.68 +/- 0.07 mmol/L) Vcfc rose to 1.10 +/- 0.03 circ/sec (P less than 0.001 compared with medium and low). CONCLUSION: Variations in Ca2+ are directly correlated with clinically significant changes in myocardial contractility.

Nephrotic syndrome from hypercalcemia in a patient with primary hyperparathyroidism.

The nephrotic syndrome developed in a 47-year-old woman in association with severe hypercalcemia (23.5 mg/dl) from primary hyperparathyroidism. Other causes for hypercalcemia were sought and were not found. The nephrotic syndrome remitted spontaneously within two weeks of normalization of the serum calcium level. Kidney biopsy specimens showed deposition of electron-dense material, thought to be calcium, in the glomerular basement membranes initially and in the mesangium as well six months later.

Recurrent reversible acute renal failure from amphotericin.

A patient with cryptogenic cirrhosis and disseminated sporotrichosis developed acute renal failure immediately following the administration of amphotericin B on four separate occasions. The abruptness of the renal failure and its reversibility within days suggests that there was a functional component to the renal dysfunction. We propose that amphotericin, in the setting of reduced effective arterial volume, may activate tubuloglomerular feedback, thereby contributing to acute renal failure.