Fluorinated anesthetic exposure "activates" the renal cortical sphingomyelinase cascade.

BACKGROUND: Previous studies indicate that fluorinated anesthetics can enhance sphingomyelin (SM) hydrolysis in in vitro neuronal extracts. Renal cortex has substantial SM content. Hence, this study assessed whether in vivo fluorinated anesthetic use stimulates renal SM hydrolysis, causing accumulation of ceramide, an important signaling molecule. METHODS: Mice were anesthetized with isoflurane or desflurane (fluorinated anesthetics). Pentobarbital anesthetized mice served as controls. After six hours, kidney cortex was assayed for ceramide. In selected experiments, renal cortical sphingosine and sphingomyelinase (SMase) levels were also determined. Isoflurane's effects on ceramide levels in cultured human proximal tubule (HK-2) cells/isolated mouse proximal tubule segments (PTS), and on in vitro 14C-SM hydrolysis were also assessed. RESULTS: Isoflurane and desflurane, but not pentobarbital, increased renal cortical ceramide levels (such as, 65% with isoflurane, P < 0.003). Isoflurane also raised PTS/HK-2 ceramide levels (by 25 to 35%). Ceramidase inhibition (fumonisin B1) did not block this ceramide accumulation in HK-2 cells. Isoflurane did not increase renal cortical/PTS SMase levels. However, it directly enhanced the ability of (acidic) SMase to effect in vitro 14C-SM hydrolysis. Isoflurane raised renal cortical sphingosine (and not just ceramide) levels, implying ongoing ceramidase activity. CONCLUSIONS: Fluorinated anesthetics can stimulate renal cortical/tubule ceramide expression, presumably by stimulating SMase-mediated SM hydrolysis. Since ceramide is a potential mediator of tubule apoptosis/necrosis, these findings have potential relevance for the development of intra/post-operative acute renal failure.

Anesthetic effects on the glycerol model of rhabdomyolysis-induced acute renal failure in rats.

Isoflurane, the most widely used inhalational anesthetic, releases inorganic fluoride during its metabolism by the cytochrome P450 system. Recent experimental data indicate that when cultured proximal tubular cells are exposed to inorganic fluoride, they become relatively resistant to myoglobin- and ATP depletion-mediated attack. The present study was undertaken to assess whether isoflurane anesthesia might confer in vivo cytoprotection, possibly by causing renal tubular inorganic fluoride exposure, thereby mitigating a combined myoglobin/ATP depletion model of acute renal failure (glycerol-induced ARF). Rats were injected with hypertonic glycerol (50%; 9 ml/kg, intramuscularly) while undergoing 4 h of isoflurane anesthesia. Glycerol-injected rats anesthetized with a virtually nondefluorinated inhalational anesthetic (desflurane) or with a nonfluorinated anesthetic (pentobarbital) served as controls. The severity of ARF was assessed 24 h later (blood urea nitrogen, plasma creatinine [Cr], and renal histology). Anesthetic effects on extrarenal injury (plasma creatine phosphokinase, lactate dehydrogenase, and hematocrit levels), acute intrarenal heme loading (cast formation), and BP during the initiation phase of renal injury (0 to 4 h after glycerol injection) were also assessed. Glycerol induced severe ARF under pentobarbital anesthesia (Cr, 2.8 +/- 0.3 mg/dl; severe tubular necrosis). Somewhat worse azotemia, but comparable tubular necrosis, resulted with desflurane use. Conversely, glycerol plus isoflurane anesthesia induced only mild renal damage (Cr, 0.9 +/- 0.1, minimal tubular necrosis; P < 0.01). This reduction apparently was not due to differences in degrees of muscle necrosis, hemolysis, acute renal heme loading, or BP during the initiation phase of ARF, suggesting that a direct renal mechanism was operative. These results: (1) underscore that differing anesthetics can profoundly alter the expression of experimental renal injury; (2) raise the intriguing possibility that isoflurane could potentially protect surgical/trauma patients from rhabdomyolysis-induced ARF; and (3) further support the concept that renal fluoride exposure may confer proximal tubular cytoprotective effects.

Altered sphingomyelinase and ceramide expression in the setting of ischemic and nephrotoxic acute renal failure.

Diverse physical and chemical stimuli can activate sphingomyelinases (SMases), resulting in sphingomyelin (SM) hydrolysis with ceramide release. Since ceramide can profoundly impact a host of homeostatic mechanisms, the concept of a "SM (or SMase) signaling pathway" has emerged. We recently documented that ceramide levels fall abruptly during renal ischemia, and then rebound to twice normal values during early reperfusion (30 to 90 min) Therefore, the present study assessed whether these ceramide changes are paralleled, and hence potentially mediated, by comparable changes in SMase activity. Mice were subjected to 45 minutes of renal ischemia +/- 30 minutes, 90 minutes, or 24 hours of reperfusion. Renal cortices (or isolated proximal tubules) were then assayed for SMase activity (acidic, neutral forms). To characterize whether early post-ischemic ceramide increments are a relatively persistent event, ceramide was assayed following a 24-hour reperfusion period. Finally, to assess whether the observed perturbations were unique to post-ischemic injury, SMase and ceramide were quantified in the setting of glycerol-induced myohemoglobinuria and anti-glomerular basement membrane (alpha GBM) antibody-induced acute renal failure (ARF). Ischemia induced abrupt declines (approximately 50%) in both acidic and neutral SMase activities, and these persisted in an unremitting fashion throughout 24 hours of reperfusion. Nevertheless, increased ceramide expression (2x normal) resulted. Myohemoglobinuria also suppressed acidic/neutral SMases, and again, "paradoxical" ceramide increments were observed. Finally, alpha GBM nephritis increased ceramide levels, but in this instance, a correlate was increased SMase activity. These results suggest that: (1) ceramide is an acute renal "stress rectant" increasing in response to diverse renal insults; (2) this response may occur independently of the classic SM pathway, since the ceramide increments can seemingly be dissociated from increased SMase activity; and (3) given the well documented impact of ceramide and the SM(ase) pathway on apoptosis, cell proliferation, differentiation, and tissue inflammation, the present results have potentially broad ranging implications for the induction and evolution of diverse forms of ARF.

Spectrum and subcellular determinants of fluorinated anesthetic-mediated proximal tubular injury.

Currently used fluorinated anesthetics are chemically related to methoxyflurane (MF), a drug that caused many cases of clinical acute renal failure during previous widespread use. To determine whether newer fluorinated anesthetics might also have nephrotoxic effects, three currently used agents (isoflurane (IF), sevoflurane (SF), and desflurane) or MF were added to rat proximal tubular segments, followed by assessments of cell integrity (ATP levels and percent lactic dehydrogenase release). Ether served as a negative control. MF, IF, and SF each induced lethal proximal tubular segment injury (up to 92, 71, and 30% lactic dehydrogenase release, respectively) and massive ATP depletion. ATP losses were observed at or near clinically relevant drug levels, they preceded lethal injury, and they correlated with approximately 50% and approximately 100% reductions in total and Na,K-ATPase-driven respiration, respectively. Clinically relevant inorganic fluoride levels simulated fluorinated anesthetic toxicity. However, fluoride release from the anesthetics (a cytochrome P450 process) did not appear to be required for toxicity (no protection with P450 inhibitors and no detectable inorganic fluoride release). As IF was judged to be one-third as toxic as MF, subclinical tubular injury (increased urine N-acetyl-beta-D-glucosaminidase (NAG) levels) after its use was sought in 19 surgical patients. Fifteen patients undergoing comparable operations with SF (approximately one-half as toxic as IF in vitro) and nine patients undergoing regional/ local anesthesia were controls. The IF group doubled its urinary NAG levels by the end of surgery (P < 0.005). Conversely, NAG levels remained stable in both control groups. The conclusions are that 1) currently used fluorinated anesthetics, particularly IF, share (but to a lesser degree) MFs tubulotoxic effects, 2) ATP depletion (probably due to decreased production) and Na,K-ATPase inhibition are likely contributing mechanisms, 3) fluoride is a prime determinant of this toxicity, and 4) tubular injury can be expressed at or near clinically relevant anesthetic/inorganic fluoride levels. That increased enzymuria can develop in patients after IF anesthesia suggests that the above in vitro data could have potential clinical relevance in selected patients.

Risk factors for renal allograft loss in patients with systemic lupus erythematosus.

Controversy exists regarding the risk factors for renal allograft loss in patients with systemic lupus erythematosus (SLE). This study is a retrospective evaluation of each of these independent risk factors in 80 renal transplants for ESRD secondary to SLE done at our institution between 1971 and 1994. Our entire non-diabetic cohort of 1,966 renal transplants is used as a comparison group. Our results showed equivalent graft survival rates between lupus patients and the cohort at 1, 5 and 10 years (P = 0.56). However, an analysis of cyclosporine-era cadaver grafts revealed that the lupus group had poorer 5-year graft survival than the cohort (41% vs. 71%, P = 0.02). Evaluation of cyclosporine-era lupus graft survival showed significantly improved outcome in living-related lupus recipients over cadaver grafts at five years (89% vs. 41%, P = 0.003). The majority of grafts lost in the lupus cadaver recipients were due to chronic rejection. Rejection was increased in lupus recipients: 69% of lupus patients experienced rejection in the first year compared to 58% of controls (P = 0.01). Stratified for age, sex, race and cyclosporine use, this difference remained significant (P = 0.003, relative risk 1.7). Nephrectomy, splenectomy and 3 to 6 months of pretransplant dialysis did not improve graft survival. A dialysis duration of greater than 25 months predicted worse graft survival (P = 0.01). Among lupus patients, PRA did not correlate with graft outcome (P = 0.5), and HLA-identical cadaver grafts had improved outcomes compared to cadaver grafts. We conclude that acute and chronic rejection are the major risk factors for graft loss in lupus patients. The superior outcome of living-related over cadaver grafts in lupus patients suggests an increased role for living-related grafts. Pretransplant dialysis, nephrectomy and splenectomy are not indicated.