Chronic mineralocorticoid excess and cardiovascular remodeling.

Chronic mineralocorticoid (MC) excess, whether due to elevated plasma aldosterone (ALDO) or deoxycorticosterone (DOC), is associated with a perivascular fibrosis of systemic and coronary arterioles. This remodeling of resistance vessels contributes to the appearance of hypertension. Chronic MC excess is also accompanied by cardiac myocyte necrosis, secondary to myocardial potassium depletion, and a subsequent reparative fibrosis that appears in the normotensive, nonhypertrophied right and hypertensive, hypertrophied left ventricles. Fibrosis contributes to the appearance of ventricular arrhythmias and dysfunction. Herein, clinical and experimental evidence linking chronic, inappropriate (relative to dietary sodium) elevations in circulating ALDO and DOC with these reactive and reparative forms of fibrous tissue formation in the heart and other tissues is presented.

Estrogen replacement therapy at menopause. How benefits outweigh risks.

Bone loss and cardiovascular disease are the most important complications of menopause. Because estrogen has been shown to prevent bone loss and also reduce fracture rates in menopausal women, the authors recommend early replacement therapy. They also examine evidence that estrogen replacement may offer these women protection from cardiovascular disease and discuss the risks of estrogen-related endometrial and breast cancer.

19-Nor-corticosteroids in genetic hypertension. Effects of inhibitors of 11 beta, 18, 19-hydroxylase activity.

The long-term objective is to understand the role of the adrenal in altering systemic arterial blood pressure. This paper summarizes research on genetic hypertension in the rat and bears a relationship to several forms of human hypertension in which defects of steroid hydroxylases lead to increased secretion of mineralocorticoids other than aldosterone in genetic and experimental hypertension in rats. We demonstrated that 19-nor-corticosteroids are produced in excess in genetic and experimental hypertension in rats and man. We studied the enzymatic alteration responsible for excessive production of 19-nor-deoxycorticosterone (19-nor-DOC) in the salt-sensitive hypertensive rat S/JR. Biosynthesis of 19-nor-steroids involves hydroxylation of the C-19 methyl group. We characterized the adrenal 11 beta, 18,19-hydroxylase enzyme system in inbred salt-sensitive and resistant rats (R/JR). This system is capable of all three hydroxylations. The Km for 19-hydroxylation was different from S/JR and R/JR but was much greater for 11 beta- and 18-hydroxylation in both. This suggested that the catalytic site for 19-hydroxylation is different from that for 11 beta and 18. The S/JR adrenal enzyme binds the substrate with higher affinity than does the R/JR adrenal enzyme. We were unable to distinguish the cDNAs of the S/JR from the R/JR adrenal enzyme from bovine 11 beta-hydroxylase cDNA by restriction mapping. We were unable to demonstrate restriction length polymorphism. 19-Acetylenic DOC is an inhibitor which preferentially inhibits the 19-hydroxylation of DOC, and does not interfere with the 18- and 11 beta-hydroxylation. This inhibition leads to a reduction in blood pressure in the S/JR Dahl rat. We suggest that an S/JR 19-nor-DOC is involved in the development of salt-sensitivity and hypertension and that inhibition of its formation by acetylenic DOC and other aromatase and non-aromatase inhibitors is associated with reversal of these phenomena.

Antihypertensive effect of 19-acetylenic-deoxycorticosterone in inbred salt-sensitive rats.

Rats susceptible to the hypertensive effect of dietary salt (SS/Jr) have excess 19-nor-deoxycorticosterone (19-nor-DOC) compared with salt-resistant control rats (SR/Jr). 19-Nor-deoxycorticosterone is a hypertensinogenic mineralocorticoid believed to contribute to the salt sensitivity of SS/Jr. 19-Acetylenic-deoxycorticosterone (19-Ac-DOC), an inhibitor of 19-nor-DOC biosynthesis, was evaluated for its antihypertensive effect in 20 hypertensive female SS/Jr rats. At 60 days of age, the rats were started on a high-salt diet (8% NaCl); then, at 120 days, the 10 surviving rats were divided into two groups. Group 1 included five animals with blood pressure +/- standard error (BP +/- SE) of 208 +/- 2 mm Hg that had 19-Ac-DOC implants (1 mg released over 10 days). Group 2 consisted of five animals with a BP of 204 +/- 2 mm Hg that had placebo implants (vehicle only). At 130 days, when another set of pellets was implanted, four rats were still alive in group 1 (BP 165 +/- 5 mm Hg) and none in group 2. At 140 days, the four surviving rats had a BP of 157 +/- 2 mm Hg. Finally, at 150 days, after 10 days off any 19-Ac-DOC, only two rats remained alive (BP 200 +/- 0 mm Hg). Urinary corticosterone +/- SE, DOC +/- SE, and 19-nor-DOC +/- SE before the first implant were 10 +/- 3, 16 +/- 5, and 42 +/- 14 micrograms/week, respectively, and 7 +/- 2, 13 +/- 5, 23 +/- 13 micrograms/week, respectively, after the second implant.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenocorticosteroid excretion in salt-sensitive and salt-resistant spontaneously hypertensive rats.

Two strains of spontaneously hypertensive rats (SHRs) differ in their susceptibility to the hypertensive effects of dietary NaCl. One strain exhibits a significant elevation of blood pressure after dietary NaCl loading (SHR-S), whereas the other does not (SHR-R). Since differences in adrenocortical steroid production may contribute to NaCl sensitivity, we compared 19-nordeoxycorticosterone (DOC), 18-OH-DOC, aldosterone, and corticosterone excretion in 6-week-old male rats from the SHR-S (n = 24) and SHR-R (n = 24) strains. The rats were housed in metabolic cages (two rats per cage) and given either basal (1%) or high (8%) NaCl diet. Urinary steroids were analyzed using thin-layer chromatography and radioimmunoassay methods. The high NaCl diet elevated the urinary excretion of the four corticosteroids in both rat strains. 19-nor-DOC decreased with time in both the SHR-S and SHR-R strains, and was not different between strains on either diet. Aldosterone was increased in the SHR-S strain compared with the SHR-R strain on the low NaCl diet, but aldosterone was not different between the two strains on the high NaCl diet. Corticosterone and 18-OH-DOC did not differ between strains. These data confirm that 19-nor-DOC is higher in young prehypertensive SHRs and decreases with age. Aldosterone excretion is higher in the SHR-S strain compared with the SHR-R strain on the low NaCl diet.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of the mineralocorticoid activity of 19-oxygenated and 19-nor derivatives of deoxycorticosterone.

19-Nordeoxycorticosterone (19-nor-DOC) is a mineralocorticoid with several unresolved physiologic questions. First, is 19-nor-DOC synthesized in the kidney from a circulating adrenocortical precursor (19-oicdeoxycorticosterone [19-oic-DOC] or 19-oxodeoxycorticosterone [19-oxo-DOC])? Second, does 19-nor-DOC, synthesized in the kidney, have mineralocorticoid activity or is it excreted in the urine without biologic activity? To answer this question, we administered two of the putative 19-nor-DOC precursors (19-oxo-DOC and 19-oic-DOC) to adrenalectomized rats and measured the formation of 19-nor-DOC and bioactivity as the urinary Na+ to K+ ratio. Each of the 10-microgram steroid treatments produced an elevation of urinary-free 19-nor-DOC (0 to 2 hours), whereas at the 1-micrograms dose only 19-oic-DOCA produced an increased UF 19-nor-DOC. None of the treatments led to an increase of conjugated 19-nor-DOC except 10 microgram 19-oic-DOCA. Increased mineralocorticoid activity (decreased urinary Na+ to K+ ratio) was produced by aldosterone, 1 and 10 micrograms 19-nor-DOC, and 10 micrograms 19-oic-DOCA over the same time period. An anti-mineralocorticoid effect (increased urinary Na+ to K+ ratio) was produced by 1 microgram 19-oxo-DOC. Urinary-free 19-nor-DOC, but not conjugated 19-nor-DOC, correlated with the urinary mineralocorticoid effect (decreased Na+ to K+ ratio). These data support the contention that 19-oic-DOC is the circulating 19-nor-DOC precursor and that, at least at the higher dose, it has a mineralocorticoid action on the kidney.(ABSTRACT TRUNCATED AT 250 WORDS)

Antihypertensive effects of an aromatase inhibitor in inbred salt-sensitive rats.

Rats susceptible to the hypertensive effect of dietary salt (SS/Jr) have excess urinary 19-nordeoxycorticosterone compared with salt-resistant control rats (SR/Jr). 19-Nordeoxycorticosterone is a hypertensinogenic mineralocorticoid, but whether it contributes to the salt sensitivity of SS/Jr is unknown. This study sought to evaluate the contribution of 19-nordeoxycorticosterone to the salt sensitivity of SS/Jr by lowering its production with an aromatase inhibitor, 10-propargyl-androst-4-ene,3,17-dione (19-acetylenic-androstenedione, 19-AA). This aromatase inhibitor also preferentially inhibits nonaromatizing adrenal 19-hydroxylation, an essential step in the formation of 19-nordeoxycorticosterone. To test this hypothesis, inhibitor (120 mg) or vehicle pellets were implanted into male and female weanling SS/Jr at 42 days of age. A high salt diet (8% NaCl) was started and two additional pellets were implanted at 52 and 62 days of age. Systolic blood pressure was measured in all animals and urinary corticosteroids in males. Compared with vehicle, the inhibitor lowered blood pressure at 50 days of age (when it could first be measured) until 64 days of age in females and 71 days of age in males. Corticosterone and aldosterone levels were not different between 19-AA- and vehicle-treated SS/Jr. 19-Nordeoxycorticosterone levels, however, were mildly reduced with the inhibitor (0.05 less than p less than 0.10). After 28 days of high salt diet all 23 of the 19-AA-treated SS/Jr were alive, whereas almost one half of the control animals had died. These data demonstrate that 19-AA attenuates the hypertension in SS/Jr; this effect may be through reduction in 19-nordeoxycorticosterone production.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of the adrenal 11 beta-hydroxylase in inbred salt-sensitive and resistant rats.

Rats have been bred for susceptibility and resistance to the hypertensive effect of dietary salt (S/JR & R/JR). S/JR have an abnormal adrenal steroid 11 beta,18-hydroxylase activity resulting in increased production of 18-OH-DOC. S/JR also produce increased quantities of 19-nor-DOC, which may be related, since the 11 beta,18-hydroxylase also catalyzes the 19-hydroxylation of DOC, a pivotal step in 19-nor-DOC biosynthesis. The purpose of the present studies was to further characterize the mutant S/JR adrenal steroid 11 beta,18-hydroxylase. Preliminary studies are also presented on assessing the renal 19-desmolase, the last step in 19-nor-DOC biosynthesis. Adrenal glands were harvested from R/JR and S/JR and prepared for incubation studies, protein immunoblotting, and RNA analysis. Kidneys from Sprague-Dawley rats were also used for isolated renal perfusion studies. Both S/JR and R/JR strains had a single immunostaining band for 11 beta,18-hydroxylase at 51,000 molecular weight which were equal in intensity. Both strains had a single RNA transcript at 4.3 kilobases which hybridized with equal intensity to the bovine cDNA (pB11-9). The Km for 11 beta- and 18-hydroxylation was identical within strains but was different between strains. The Km for 19-hydroxylation was different between S/JR and R/JR, and was much greater than 11 beta- and 18-hydroxylation in both strains. This suggests that the catalytic site for 19-hydroxylation is different than that for 11 beta- and 18-hydroxylation and that the S/JR enzyme binds the substrate with higher affinity than the R/JR enzyme. In the isolated perfusion studies the rat kidneys converted 80% of 19-oxo-DOC to either 19-oic-DOC or 19-nor-DOC. These data demonstrate that the difference in S/JR enzyme activity is probably due to a point mutation in the enzyme or to a change in a regulatory protein.

Elevated 18-hydroxy-corticosterone in inbred salt-sensitive rats.

Rats susceptible to the hypertensive effect of dietary salt (SS/Jr) have excess 18-hydroxydeoxycorticosterone (18-OH-DOC) and 19-nor-DOC compared to control rats (SR/Jr). This may be caused by an abnormal adrenal 11 beta-hydroxylase, which catalyzes the 11 beta, 18, and 19-hydroxylations of DOC. A comparison of the urinary products of this enzyme including 18-OH-DOC, 19-nor-DOC, corticosterone (B), and 18-OH-B have not been described in the SS/Jr. Therefore, these steroid products were measured at 7 and 12 weeks of age in 36 weanling male and female, SS/Jr and SR/Jr (n = 9 in each group), on a low-salt diet. In both the male and female SS/Jr urinary free levels of 18-OH-DOC, 19-nor-DOC, and 18-OH-B were elevated, while B was not different at 6 and 10 weeks of age. The largest increases were in 18-OH-B levels, and these levels correlated with 18-OH-DOC and B but not 19-nor-DOC. The high degree of correlation between these steroids probably reflects their closely related dependence on adrenal 11 beta-hydroxylase biosynthesis.

Alterations in aldosterone secretion and metabolism in low renin hypertension.

Low renin essential hypertensives (LRH) have normal plasma aldosterone levels which are inappropriately high in relation to their PRA. Posture is the major determinant for plasma aldosterone and PRA levels, but it is not known whether postural increments (delta) of plasma aldosterone and (delta) PRA are also abnormal in LRH. To evaluate this, LRH (n = 8), normal renin hypertensives (NRH; n = 9), normotensive controls (n = 18), and subjects with idiopathic hyperaldosteronism (IHA; n = 5) were studied in a metabolic unit on a controlled diet over 7 days. Overnight supine and 4-h upright PRA, plasma aldosterone, and 24-h urinary tetrahydroaldosterone (THA) and aldosterone secretion rates (ASR) were measured. The delta in plasma aldosterone after 4 h of upright posture was not different in the four groups. The ratio of delta plasma aldosterone/delta PRA, however, was elevated in both IHA and LRH compared to that in NRH and normals. THA excretion was also elevated in IHA and LRH, but LRH had a normal ASR. This resulted in a higher fractional THA excretion (THA/ASR) in LRH compared to the other three groups. These data further support enhanced adrenal angiotensin-II sensitivity in LRH. Aldosterone was preferentially metabolized to THA in LRH. Since THA has reduced biological activity, this may be a compensatory mechanism to reduce mineralocorticoid activity in LRH.

Renal 21-hydroxylation of 19-hydroxy-progesterone to 19-hydroxy-deoxycorticosterone.

19-Nor-deoxycorticosterone (19-nor-DOC) is a mineralocorticoid present in both rat and human urine, and it is elevated in some forms of experimental and human hypertension. Although the exact steps in the biosynthesis of 19-nor-DOC are uncertain, it is probably produced from a 19-oxygenated derivative of DOC, which undergoes 19-desmolation in the kidney. Since DOC biosynthesis is partly due to renal 21-hydroxylation of progesterone (Prog), we sought to determine whether a parallel pathway could exist for the biosynthesis of 19-hydroxy-DOC, a precursor to 19-nor-DOC. In order to test this hypothesis, authentic 19-hydroxy-progesterone was incubated with homogenized renal tissues from either rat or human sources. Formation of 19-hydroxy-DOC was found to be the major metabolite in both rat and human incubations, as demonstrated by an HPLC retention time identical to authentic 19-hydroxy-DOC. 19-Hydroxy-DOC formation was further verified by GC/MS analysis with highly sensitive selected ion recording. Since it has been demonstrated that the placenta can convert progesterone to 19-hydroxy-progesterone, the renal 21-hydroxylation of 19-hydroxy-progesterone to 19-hydroxy-DOC could be an alternate pathway of 19-nor-DOC production especially during pregnancy.

19-Hydroxylase inhibition of adrenal mitochondrial P450 11 beta/18/19-hydroxylase by a suicide inhibitor.

19-Nor-deoxycorticosterone (19-nor-DOC) is a mineralocorticoid that is increased in some forms of experimental and human hypertension. The pivotal step in 19-nor-DOC biosynthesis is adrenal P450 19-hydroxylase, but this enzyme has not been clearly distinguished from P450 11 beta/18-hydroxylase. This study attempted to specifically inhibit adrenal 19-hydroxylation of deoxycorticosterone (DOC) using a suicide aromatase inhibitor, 19-acetylenic androstenedione (19-AA). Purified bovine P450 11 beta/18/19-hydroxylase was incubated with excess substrate DOC, adrenodoxin, and adrenodoxin reductase in the presence of increasing doses of the inhibitor, 19AA. 11 beta-, 18-, and 19-hydroxylation were measured by quantification of corticosterone, 18-OH-DOC, and 19-OH-DOC respectively. Measurements of these products demonstrated that 11 beta- and 18-hydroxylation was not inhibited whereas 19-hydroxylation was inhibited as manifested by decreased 19-OH-DOC formation (p less than .05). The IC50 of 19-AA was approximately 10(-12) M. The specific inhibition of 19-hydroxylation suggests that the 19-hydroxylase may be an enzyme distinct from the P450 11 beta/18-hydroxylase. This further suggests that 19-nor-DOC biosynthesis may be under independent regulation and may be amendable to specific in vivo inhibition.

Reversal of diuretic-induced secondary hyperaldosteronism and hypokalemia by trilostane, an inhibitor of adrenal steroidogenesis.

Correction of diuretic-induced hypokalemia is usually accomplished by potassium supplementation or antagonism of aldosterone's renal action. This study sought to determine if inhibition of aldosterone biosynthesis could reverse diuretic-induced hypokalemia and whether trilostane would be clinically useful in this regard. Essential hypertensives (n = 22) were treated with hydrochlorothiazide (HCTZ) 50 mg/d, and patients who became hypokalemic were randomly assigned to receive in addition to HCTZ either a placebo (n = 7), trilostane 240 mg/d (Trilo 240) (n = 7), or trilostane 60 mg/d (Trilo 60) (n = 3). Following 12 weeks of therapy the placebo patients remained hypokalemic with hyperaldosteronism, while the patients who received Trilo 240 had a correction of hypokalemia and hyperaldosteronism (P less than .05) along with a reduction in diastolic blood pressure (P less than .05). The Trilo 60 patients, however, remained hypokalemic with no significant reduction in aldosterone excretion or blood pressure compared with HCTZ. Body weight and urinary free cortisol levels along with routine biochemical tests were unchanged during this study. Three Trilo 240 patients developed diarrhea but did not discontinue the study. These results demonstrate that trilostane can correct diuretic-induced hypokalemia by lowering aldosterone secretion. Furthermore, this reduction in aldosterone may enhance the antihypertensive effects of diuretic therapy.

An adrenal cyst associated with 19-nor-deoxycorticosterone excess and low renin hypertension.

Adrenal cysts are rare, but they have been disproportionately associated with hypertension. This report describes a hypertensive patient with increased levels of 19-nor-deoxycorticosterone (19-nor-DOC), a potent mineralocorticoid. The patient was a thirty year old man with hypokalemia, moderately severe hypertension, suppressed PRA, and low aldosterone secretion. Following surgical removal of a 10 cm adrenal cyst, the hypertension improved, the hypokalemia resolved, and the PRA and the aldosterone secretion normalized. Urinary 19-nor-DOC pre-op was elevated 4.6 microgram per day (normal less than 1.0 microgram/day and subsequently became normal at 0.7 microgram per day following surgery. The adrenal cyst was a fibrous walled structure containing mucinous straw-colored fluid. Pericystic adrenocortical tissue demonstrated increased 19-OH-DOC production (a 19-nor-DOC precursor) which may have been responsible for the 19-nor-DOC excess. We hypothesize that compressive adrenal damage from the cyst may produce a form of adrenal regeneration hypertension which is known to be associated with 19-nor-DOC excess.

Identification of 19-hydroxy-progesterone in human placenta.

We have tentatively demonstrated the presence of a 19-hydroxylated C21 steroid, 19-hydroxy-progesterone, in normal human placenta. A 19-hydroxylated steroid such as 19-hydroxy-progesterone, if produced by the placenta, could serve as a precursor for such hypertensinogenic 19-nor-steroids as 19-nor-deoxycorticosterone and 19-nor-progesterone. Freshly delivered, homogenized placental tissue was extracted and subjected to thin layer chromatography. A steroid corresponding to standard 19-hydroxy-progesterone was subsequently purified in HPLC, where authentic 19-hydroxy-progesterone and the sample had the same retention time. The identity of the sample was further confirmed by repeat HPLC after acetylation and mass spectrometry. Our experiment indicates that 19-hydroxy-progesterone is present in term placental tissue, where it appears to be synthesized.

Selective 19-hydroxylase inhibition by an aromatase inhibitor, 4-hydroxyandrostenedione.

19-Nor-deoxycorticosterone is a newly recognized mineralocorticoid which has been associated with some forms of genetic, experimental, and human hypertension. To further examine this relationship, specific inhibitors of 19-nor-deoxycorticosterone biosynthesis must be developed. Since 19-hydroxylation is the pivotal step in both 19-nor-deoxycorticosterone biosynthesis and aromatization of androgens to estrogens, we evaluated an aromatase inhibitor, 4-hydroxyandrost-4-ene-3,17-dione on the inhibition of 19-hydroxylation in both rat and human adrenal mitochondria in vitro and 19-nor-deoxycorticosterone production and blood pressure in spontaneously hypertensive rats in vivo. Adrenal mitochondria from 48 male Sprague-Dawley rats and 1 patient with an aldosterone-producing adenoma were incubated in the presence of deoxycorticosterone substrate both with and without 4-hydroxyandrost-4-ene-3,17-dione. 4-Hydroxyandrost-4-ene-3,17-dione produced significant inhibition of 19-hydroxy-deoxycorticosterone production in both rat and human adrenal mitochondria, with a smaller and not significant inhibition of corticosterone and 18-hydroxy-corticosterone. 4-Hydroxyandrost-4-ene-3,17-dione given subcutaneously to spontaneously hypertensive rats lowered 19-nor-deoxycorticosterone by 69% and completely abolished hypertension compared to Wistar-Kyoto controls. These data demonstrate that 4-hydroxyandrost-4-ene-3,17-dione is a specific inhibitor of 19-hydroxylase, that it lowers 19-nor-deoxycorticosterone production and prevents hypertension in the spontaneously hypertensive rat. These studies reinforce the possible pathogenic significance of 19-nor-deoxycorticosterone in hypertension in spontaneously hypertensive rats.