Acute tubulointerstitial nephritis with an autoantibody response against carbonic anhydrase II.

An autoantibody against carbonic anhydrase II was identified in a case of acute tubulointerstitial nephritis induced by famotidine, which inhibits carbonic anhydrase II in addition to the gastric proton pump. The patient's serum reacted with distal nephron homogenates at the same molecular weight as purified carbonic anhydrase II, and immunohistochemistry using the patient's serum showed staining at the distal nephron. Carbonic anhydrase II may be a causative antigen in the famotidine-induced acute tubulointerstitial nephritis.

Long-term renal prognosis of IgA nephropathy with therapeutic trend shifts.

OBJECTIVE: We compared the effect of treatments in the long-term renal survival of IgA nephropathy. METHODS: One hundred and fourteen patients with biopsy-proven IgA nephropathy were retrospectively divided into 4 groups, reflecting shifts in treatment trends from 1985 to 2005: patients without treatment (no treatment group; n=36), patients treated only with anti-platelet drugs (anti-platelet group; n=12), those treated mainly with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) (ACEI/ARB group; n =29), and prednisolone-treated patients (PSL group; n =37). RESULTS: Baseline blood pressure, serum creatinine and renal histological findings were similar among the 4 groups; however, the urinary protein level was significantly severer in the PSL group. After a mean follow-up of 7.0+/-0.5 years, end-stage renal disease occurred in 11 patients (31%) in the no treatment group, 5 patients (42%) in the anti-platelet group and 3 patients (8%) in the PSL group, but in only 1 patient (3%) in the ACEI/ARB group. Kaplan-Meier renal survival after 20 years was significantly better in the ACEI/ARB group than in the anti-platelet group or in the no treatment group (p<0.05). The patients that reached complete remission (CR) by steroid therapy showed less baseline urinary protein and milder histological lesions than those who did not reach CR. The non-CR group showed increases in serum creatinine and eGFR reduction rate. CONCLUSION: Treatment with renin-angiotensin system inhibitors showed the greatest improvement of 20-year renal survival in IgA nephropathy patients. Steroid therapy achieved complete remission in some early-stage cases.

Dual blockade of aldosterone and angiotensin II additively suppresses TGF-beta and NADPH oxidase in the hypertensive kidney.

BACKGROUND: Angiotensin II blockade and spironolactone effectively reduces proteinuria in humans. To clarify the mechanisms of the beneficial effect of blockade of both aldosterone and angiotensin II, we associated the aldosterone antagonist eplerenone to an angiotensin-converting enzyme inhibitor (ACEI) and examined the effect on renal transforming growth factor (TGF)-beta expression and oxidative stress by nicotinamide adenine dinucleotide phosphate (NADPH) oxidase in the Dahl salt-sensitive rat with heart failure (DSHF). METHODS: Dahl salt-resistant control rats and DSHF rats were fed with 8% NaCl diet and at 11 weeks the DSHF rats were treated with vehicle, eplerenone (Epl), trandolapril or a combination of both drugs for 7 weeks. RESULTS: DSHF rats showed increased NADPH oxidase and decreased superoxide dismutase (SOD) resulting in increased oxidative stress. ACEI and Epl reduced NADPH oxidase showing an additive effect in their combination; ACEI increased manganese SOD (MnSOD) and Epl increased MnSOD, copper-zinc SOD and catalase, resulting in the lowest levels of oxidative stress with the combination therapy. Glomerulosclerosis and proteinuria were increased in the DSHF rats, and Epl suppressed them more effectively than ACEI to levels not different from the combination of both, showing a positive correlation with NADPH oxidase expression and TGF-beta. Renal TGF-beta was specifically suppressed with Epl CONCLUSION: The association of Epl to ACEI is beneficial due to further reduction of NADPH oxidase and specific inhibition of TGF-beta resulting in improvement of renal damage.

Double-edged action of SOD mimetic in diabetic nephropathy.

Oxidative stress plays an important role in the pathogenesis of diabetic complications, and we investigated the effect of superoxide dismutase (SOD) mimetic, tempol, in diabetic nephropathy. Streptozotocin-induced diabetic rats were treated with tempol from 2 weeks until 8 weeks. The expression of NADPH oxidase, catalase, and myeloperoxidase (MPO), superoxide dismutase activity, and production of peroxide and hypochlorite were evaluated. Tempol treatment prevented the increase in NADPH oxidase and peroxide production in the glomeruli of diabetic rat. Catalase was decreased without change in SOD activity, and MPO was enhanced in the kidney of diabetic rats. Tempol treatment stimulated SOD activity and increased the conversion of superoxide to hydrogen peroxide, and hydrogen peroxide on its hand was converted to hypochlorite by the increased MPO. The reduction of peroxide by tempol was followed by the decrease in TGF-beta and mesangial matrix expansion. However, tempol did not reduce hypochlorite or urinary protein excretion. In conclusion, tempol inhibited glomerular matrix expansion via suppression of peroxide production and TGF-beta, but it failed to reduce proteinuria, probably due to the increased hypochlorite production in diabetic nephropathy.

Sarcoidosis with acute recurrent polyarthritis and hypercalcemia.

A 45-year-old woman had bleary eyes and recurrent episodes of fever and arthritis in the knees and ankles. The patient had anterior uveitis, negative findings of the tuberculin test, and an increased serum lysozyme level, but bilateral hilar lymphadenopathy (BHL) was absent. During the course of her disease, the serum calcium and angiotensin-converting enzyme levels gradually increased to above the normal level, and the patient was clinically diagnosed as having sarcoidosis. The clinical features of arthritis were typical of those of Löfgrens syndrome although BHL and erythema nodosum were absent. The patient was successfully treated with 15 mg/day of prednisolone.

Endogenous prostaglandin D(2) synthesis decreases vascular cell adhesion molecule-1 expression in human umbilical vein endothelial cells.

We examined the role of prostaglandin D(2) (PGD(2)) in the expression of vascular cell adhesion molecule-1 (VCAM)-1 following interleukin-1beta (IL-1) stimulation in human umbilical vein endothelial cells (HUVEC) transfected with lipocaline-type PGD(2) synthase (L-PGDS) genes. HUVEC were isolated from human umbilical vein and incubated with 20 U/ml IL-1 and various concentrations of authentic PGD(2). The isolated HUVEC were also transfected with L-PGDS genes by electroporation. The L-PGDS-transfected HUVEC were used to investigate the role of endogenous PGD(2) in IL-1-stimulated VCAM-1 biosynthesis. We also used an anti-PGD(2) antibody to examine whether an intracrine mechanism was involved in VCAM-1 production. PGD(2) and VCAM-1 levels were determined by radio- and cell surface enzyme-immunoassay, respectively. VCAM-1 mRNA was assessed by RT-PCR. IL-1-stimulated VCAM-1 expression by HUVEC was dose-dependently inhibited by authentic PGD(2). L-PGDS gene-transfected HUVEC produced more PGD(2) than HUVEC transfected with the reporter gene alone. IL-1 induced increases in VCAM-1 expression in HUVEC transfected with reporter genes alone. However, this effect was significantly attenuated in the case of IL-1 stimulation of HUVEC transfected with L-PGDS genes, and accompanied by an apparent suppression of VCAM-1 mRNA expression. Neutralization of extracellular PGD(2) by anti-PGD(2)-specific antibody influenced neither VCAM-1 mRNA expression nor VCAM-1 biosynthesis. In conclusion, HUVEC transfected with L-PGDS genes showed increased PGD(2) synthesis. This increase was associated with attenuation of both VCAM-1 expression and VCAM-1 mRNA expression. The results suggest that endogenous PGD(2) decreases VCAM-1 expression and VCAM-1 mRNA expression, probably through an intracrine mechanism.

Effects of NADPH oxidase inhibitor in diabetic nephropathy.

BACKGROUND: We used apocynin to test the hypothesis that superoxide anion (O(-) (2)) from nicotinamide adenine dinucleotide phosphate (NADPH) oxidase underlies the development of diabetic nephropathy in the rat. METHODS: Rats received apocynin (16 mg/kg/day) from 2 to 8 weeks after inducing diabetes mellitus (DM) with streptozotocin. RESULTS: DM increased excretion of hydrogen peroxide (H(2)O(2)), lipid peroxidation products (LPO), nitric oxide products (NOx), and protein. The kidneys of rats with DM had increased expression of p47phox and gp91phox and endothelial nitric oxide synthase (eNOS), and increased mesangial matrix with expression of fibronectin and collagen I. Apocynin prevented the increase in excretion of H(2)O(2), LPO, and protein in diabetic rats, increased renal NOx generation, and prevented the increased renal expression of gp91phox and the membrane fraction of p47phox, and reverted the mesangial matrix expansion. CONCLUSION: Activation of NADPH oxidase with translocation of p47phox to the membrane underlies the oxidative stress and limited NO generation, despite enhanced eNOS expression in a model of diabetic nephropathy. Apocynin prevents these changes and the associated proteinuria.

Antioxidative effect of p38 mitogen-activated protein kinase inhibitor in the kidney of hypertensive rat.

OBJECTIVE: Nicotinamide adenine dinucleotide phosphate (NAD(P)H) oxidase is regulated by angiotensin II, interleukin (IL)-1beta and tumor necrosis factor (TNF)-alpha via p38 mitogen-activated protein kinase (MAPK). We hypothesized that p38 MAPK inhibitor, FR167653, may suppress NAD(P)H oxidase and its oxygen radical production and ameliorate renal damage in Dahl salt-sensitive rats with heart failure (DSHF). METHODS: DSHF rats were fed with 8% NaCl diet from 6 to 18 weeks old. Eleven-week-old DSHF rats received either vehicle or FR167653 (2 mg/kg per day) for 7 weeks and the renal NAD(P)H oxidase p47phox and nitric oxide synthase (NOS), superoxide production and renal damage were evaluated in comparison with the control Dahl salt-resistant rat fed with 8% NaCl diet. RESULTS: In the kidney of DSHF rat, phosphorylated p38 MAPK was enhanced with an increased IL-1beta and TNF-alpha production compared with control rats. Treatment with FR167653 significantly suppressed p38 MAPK, IL-1beta and TNF-alpha. Renal NAD(P)H oxidase p47phox expression and superoxide production were significantly increased in the DSHF rats and treatment with FR167653 suppressed NAD(P)H oxidase expression and reduced superoxide formation. Renal endothelial and inducible NOS were reduced in DSHF rats compared with control rats, but FR167653 increased NOS and NO production in the kidney. Proteinuria, glomerulosclerosis and interstitial macrophage migration via intercellular adhesion molecule-1 (ICAM-1) were enhanced in DSHF rat and they were ameliorated by FR167653. CONCLUSION: The inhibition of p38 MAPK by FR167653 reduced renal IL-1beta and TNF-alpha production and ameliorated renal damage in hypertensive rat via suppression of NAD(P)H oxidase and enhanced NO bioavailability.

Blood pressure response to erythropoietin injection in hemodialysis and predialysis patients.

Recombinant human erythropoietin (rHuEPO) has been reported to induce hypertension. We investigated the effect of a single injection of rHuEPO on blood pressure in patients receiving hemodialysis (HD) and in patients with predialysis chronic renal failure (CRF). Forty-one patients receiving HD and 36 patients with predialysis CRF received an intravenous injection of rHuEPO, and blood pressure and plasma endothelin-1 were measured before and 30 min after the injection. Mean blood pressure was increased significantly in HD patients, but not in CRF patients (HD: 103+/-5 to 105+/-6 mmHg, p<0.05; CRF: 103+/-4 to 103+/-6, NS). The percentage of patients with increased mean blood pressure of more than 10 mmHg after rHuEPO injection was significantly larger in the HD than in the CRF group (27.0% vs. 5.5%, p<0.01). A positive correlation was found between changes in endothelin-1 level and mean blood pressure in the HD (r=0.43, p<0.01) but not in predialysis chronic renal failure. In conclusion, a single injection of rHuEPO increased blood pressure with a positive correlation with endothelin-1 release in hemodialysis patients, but not in predialysis chronic renal failure patients.

Radical scavenging effect of gliclazide in diabetic rats fed with a high cholesterol diet.

BACKGROUND: Gliclazide is a sulphonylurea antidiabetic drug with anti-oxidant effect due to its azabicyclo-octyl ring. We hypothesized that gliclazide may have a beneficial effect on diabetic nephropathy via radical scavenging. METHODS: Streptozotocin-induced diabetic rats fed a 4% cholesterol diet [high cholesterol-diabetes mellitus (HC-DM)] (N= 12) were treated with gliclazide (HC-DM + gliclazide) (N= 12) or glibenclamide (HC-DM + glibenclamide) (N= 12) after 2 weeks of the diabetes induction, and normal rat fed with 4% cholesterol served as control [high cholesterol-control (HC-control)] (N= 12). Renal expression of endothelial nitric oxide synthase (eNOS) and intracellular adhesion molecule-1 (ICAM-1), oxidative stress production via nicotinamide adenine dinucleotide phosphate (NAD(P)H) oxidase and antioxidant enzyme manganese superoxide dismutase (MnSOD) were evaluated at 4 weeks and renal damage was examined at 8 weeks. RESULTS: HC-DM showed significant increase in renal NAD(P)H oxidase and reduction in MnSOD with a significant increase in urinary lipid peroxidation products and H2O2 excretion compared to HC-control. Gliclazide treatment, but not glibenclamide, significantly reduced the oxidative products and NAD(P)H oxidase. There was no difference in renal eNOS expression between HC-DM and HC-control rats, and only gliclazide treatment enhanced eNOS expression. Renal damage evaluated by increased glomerular macrophage migration via enhanced ICAM-1 expression, mesangial matrix expansion, and albuminuria was significantly increased in HC-DM, and they were ameliorated by gliclazide but not by glibenclamide. CONCLUSION: Gliclazide reduced oxidative stress in diabetic rats fed a high cholesterol diet with reduction of renal NAD(P)H oxidase expression, enhanced MnSOD and eNOS expression, and had a beneficial effect on glomerular macrophage infiltration and mesangial expansion.

Urinary fatty acid-binding protein as a new clinical marker of the progression of chronic renal disease.

Previous studies have indicated that in massive proteinuria, free fatty acids (FFAs) bound to albumin were overloaded in the proximal tubule and exacerbated tubulointerstitial damage. Liver-type fatty acid-binding protein (L-FABP) is an intracellular carrier protein of FFAs that is expressed in the proximal tubule of human kidney. We sought to evaluate urinary L-FABP as a clinical marker in chronic renal disease. Urinary L-FABP was measured in patients with nondiabetic chronic renal disease (n = 120) with the use of a newly established ELISA method. We then monitored these patients for 15 to 51 months. Clinical data were analyzed with multivariate analysis. Urinary L-FABP was correlated with urinary protein, urinary alpha(1)-microglobulin, and serum creatinine concentrations. Urinary L-FABP at the start of follow-up (F = 17.1, r =.36, P <.0001) was selected as a significant clinical factor correlated with the progression rate, defined as a slope of a reciprocal of serum creatinine over time. We next selected the patients with mild renal dysfunction (n = 35) from all 120 patients and divided them into 2 groups according to progression rate: the progression group (n = 22) and the nonprogression group (n = 13). Serum creatinine and urinary protein concentrations and blood pressure at the start of follow-up were higher in the progression group than in the nonprogression group, although we detected no significant difference between the 2 groups. Urinary L-FABP was significantly higher in the former group than in the latter (P <.05). The results showed that urinary L-FABP reflected the clinical prognosis of chronic renal disease. Urinary L-FABP may be a clinical marker that can help predict the progression of chronic glomerular disease.

Calcineurin promotes the expression of monocyte chemoattractant protein-1 in vascular myocytes and mediates vascular inflammation.

Although the role of the calcineurin-dependent pathway in the development of cardiac hypertrophy has been intensively studied, little is known of its role in vascular inflammatory diseases such as atherosclerosis and restenosis after angioplasty. To help elucidate the role of calcineurin in vascular inflammation, we infected cultured vascular smooth muscle cells (VSMCs) with an adenovirus construct expressing a constitutively active mutant of calcineurin, and examined its effect on the expression of monocyte chemoattractant protein-1 (MCP-1). We also examined the role of calcineurin in vivo using a transluminal wire injury model of the rat femoral artery. Forced activation of calcineurin significantly increased the expression of MCP-1 both at the transcriptional and protein levels. Angiotensin II (Ang II) also significantly stimulated MCP-1 expression, and this increase was significantly inhibited by cyclosporin A (CyA). Constitutive activation of calcineurin stabilized MCP-1 mRNA without enhancing MCP-1 promoter activity. In accordance with the results, Ang II-induced increase of MCP-1 promoter activity was not suppressed by CyA. Ang II stabilized MCP-1 mRNA, and this effect of Ang II was diminished by CyA. CyA suppressed MCP-1 expression in the femoral artery after the transluminal mechanical injury. CyA also inhibited macrophage infiltration and neointimal formation in the wire-injured femoral arteries. These results suggested that calcineurin mediates vascular inflammation via stimulation of MCP-1 expression in VSMCs and macrophage infiltration.

Angiotensin II blockade restores albumin reabsorption in the proximal tubules of diabetic rats.

The kidney plays an important role in protein metabolism. The albumin reabsorption in the proximal tubule is disturbed in the early stage of diabetic nephropathy. We evaluated the effects of angiotensin converting enzyme inhibitor (ACEI) and angiotensin III type 1 receptor blocker (ARB) on albumin reabsorption and expression of megalin, an endocytosis receptor for albumin, in proximal tubules of streptozotocin (STZ)-induced diabetic-rats. Diabetic rats at the second week after STZ injection were treated with quinapril (3 mg/kg/day) or candesartan (0.05 mg/kg/day) for 2 weeks. The tubular reabsorption of fluorescein isothiocyanate (FITC)-labeled albumin was evaluated by immunogold electron microscopy, and megalin expression was investigated by immunohistochemistry and Western blotting. Reabsorption of FITC-labeled albumin and megalin expression were prominently inhibited in the proximal convoluted tubules of diabetic rats compared to the controls. Both quinapril and candesartan restored albumin reabsorption in the proximal tubule due to normalization of megalin expression. Urinary albumin excretion was significantly reduced by both ACEI and ARB treatment. Angiotensin II infusion decreased megalin expression and albumin reabsorption in the proximal tubule. In conclusion, angiotensin II blockade restored albumin reabsorption via amelioration of megalin expression in the proximal tubules of early stage diabetic rats.

Effects of cholesterol-lowering therapy on pressor hyperreactivity to stress in hypercholesterolemic patients.

We previously demonstrated that normotensive patients with hypercholesterolemia showed excessive blood pressure (BP) responses to stress tests. In this study, we examined the effects of cholesterol-lowering therapy on BP in order to confirm that hypercholesterolemia plays a role in the regulation of BP. Fifteen patients with hypercholesterolemia and 24 normal cholesterolemic controls performed mental arithmetic stress (AS) and hand grip (HG) tests. BP was measured during the tests. Serum lipids and lipid peroxides were measured before the AS. Platelet intracellular free calcium concentration ([Ca2+])i with and without low density lipoprotein (LDL) stimulation, plasma cGMP and NOx were determined immediately before AS and at the end of each test. In hypercholesterolemic patients, the tests were repeated at the end of a 12-week treatment with 10 mg/day of pravastatin, a hepatic hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor. In hypercholesterolemic patients, BP responses to both tests were greater than those of the controls. Basal and LDL-stimulated platelet [Ca2+]i were higher, and the ratio of plasma cGMP to NOx was lower. Serum total cholesterol, LDL cholesterol and lipid peroxides were significantly decreased in association with the pravastatin treatment. Systolic BP to AS and systolic BP/diastolic BP to HG were decreased (p < 0.01, p < 0.01/p < 0.02, respectively). Platelet [Ca2+]i with LDL stimulation was decreased (p < 0.01). Plasma cGMP was increased (p < 0.05), whereas NOx was decreased (p < 0.05); therefore, the ratio of cGMP to NOx was increased (p < 0.05). In conclusion, excessive blood pressure responses to stress tests were improved after cholesterol-lowering therapy. This finding suggests that hypercholesterolemia itself is involved in the regulation of BP.

Biphasic regulation of renal proximal bicarbonate absorption by luminal AT(1A) receptor.

Angiotensin II (AngII) regulates renal proximal transport in a biphasic way. It has been recently shown that the basolateral type 1A receptor (AT(1A)) mediates the biphasic regulation of Na(+)-HCO(3)(-) cotransporter (NBC) by AngII. However, the receptor subtype(s) responsible for the luminal AngII actions remained to be established. To clarify this issue, the luminal AngII effects in isolated proximal tubules from wild-type (WT) and AT(1A)-deficient mice (AT(1A) KO) were compared. In WT, the rate of bicarbonate absorption (JHCO(3)(-)), analyzed with a stop-flow microspectrofluorometric method, was stimulated by 10(-10) mol/L luminal AngII but was inhibited by 10(-6) mol/L luminal AngII. Both stimulatory and inhibitory effects of AngII were completely blocked by valsartan (AT(1) antagonist) but unaffected by PD 123,319 (AT(2) antagonist). In AT(1A) KO, in contrast, luminal AngII (10(-10) - 10(-6) mol/L) did not change JHCO(3)(-). In WT, 10(-6) mol/L luminal AngII increased cell Ca(2+) concentrations ([Ca(2+)](i)), which was again blocked by valsartan but not by PD 123,319. However, luminal AngII did not increase [Ca(2+)](i) in AT(1A) KO. On the other hand, the addition of arachidonic acid similarly inhibited JHCO(3)(-) in WT and AT(1A) KO. Furthermore, the acute activation of protein kinase C by phorbol 12-myristate 13-acetate similarly stimulated JHCO(3)(-) in WT and AT1A KO, indicating that the inhibitory and stimulatory pathways necessary for the AngII actions were preserved in AT(1A) KO. These results indicate that the luminal AT(1A) mediates the biphasic regulation of bicarbonate absorption by luminal AngII, while no evidence was obtained for a role of AT(2).

Effects of the anti-platelet aggregation drug dilazep on cognitive function in Dahl salt-sensitive rats.

Among the consequences of the increasing prolongation of lifespan is a worldwide increase in the number of cases of dementia or impaired cognition. In the present study, to test the hypothesis that mechanisms independent of high blood pressure are involved in maintaining cognitive function, we assessed the effects of long-term dilazep treatment on cognitive dysfunction in normotensive Dahl salt-sensitive (Dahl S) rats fed a low-salt diet, using the standard passive avoidance test. Normotensive Dahl S rats fed a 0.3% NaCl diet were treated for 6 months with low-dose dilazep (2.5 microg/ml in drinking water) or high-dose dilazep (12.5 microg/ml). Systolic blood pressure was within normotensive range throughout the study and did not differ among the experimental groups. The results of the passive avoidance test revealed that dilazep treatment attenuated the decline of latency time relative to that in the untreated control rats (control latency time, 235 s; low-dilazep group, 389 s; high-dilazep group, 397 s), suggesting that the cognitive function of normotensive Dahl S rats was improved by dilazep treatment. This improvement of cognition was associated with significant increases in the number of neuronal cells in the hippocampal region and with an increase in capillary length in dilazep-treated Dahl rats. In addition, the dilazep treatments significantly attenuated arteriolar injury of glomeruli in the kidney. These data suggest that dilazep treatment, through vascular and non-vascular effects, maintains the brain function in Dahl S rats susceptible to vascular injury and organ dysfunction.

Effect of combination therapy with dipyridamole and quinapril in diabetic nephropathy.

BACKGROUND/AIMS: Dipyridamole stimulates nitric oxide action via inhibition of phosphodiesterase and also has an antioxidant effect. ACE inhibitor reduces glomerular pressure and enhances NO action via increased bradykinin. Thus, we evaluated the effect of the combination of dipyridamole and ACE inhibitor in diabetic nephropathy. METHODS: Streptozotocin-induced diabetic rats at 2 weeks were treated with dipyridamole, quinapril or both. The expression of NOS and NAD(P)H oxidase p47phox was investigated using immunohistochemistry and western blot, and urinary albumin, cGMP and lipid peroxidation products (LPO) were measured at 4 weeks. RESULTS: NAD(P)H oxidase and urinary LPO were significantly enhanced in diabetes, and suppressed by each treatment to the same extent. The nNOS expression in macula densa and eNOS increased significantly with combination therapy compared to quinapril treatment alone contributing to an enhanced urinary excretion of cGMP and to maintain the creatinine clearance. Increased albuminuria in diabetes was reduced more effectively with combination therapy to the control level than with single treatments. CONCLUSION: Combination therapy with dipyridamole and quinapril suppressed urinary LPO via reduction of NAD(P)H oxidase increase in diabetes. The combination therapy reduced microalbuminuria to the control level and maintained creatinine clearance with enhanced nNOS and eNOS expression compared to quinapril alone.