A case of gain-of-function mutation in calcium-sensing receptor: supplemental hydration is required for renal protection.

AIMS: The calcium-sensing receptor (CaSR) regulates the extracellular calcium level, mainly by controlling parathyroid hormon secretion and renal calcium reabsorption. In gain-of-function CaSR mutations, the genetic abnormalities increase CaSR activity leading to the development of such clinical manifestations as hypercalciuric hypocalcemia and hypoparathyroidism. We report a Japanese case of CaSR gain-of-function mutation and represent a therapeutic intervention based on the functional characteristics of CaSR in renal tubule. METHODS AND RESULTS (CASE): DNA sequence analysis revealed a heterozygous G to T mutation identified in a 12-year-old Japanese girl presenting with sporadic onset of hypercalciuric hypocalcemia and hypoparathyroidism. The mutation is located in the N-terminal extracellular domain of the CaSR gene, one of the most important parts for the three-dimensional construction of the receptor, resulting in the substitution of phenylalanine for cysteine at amino acid 131 (C131F) in exon 3. Based on the diagnosis of the gain-of-function mutation in the CaSR, oral hydrochlorothiazide administration and supplemental hydration were started in addition to calcium supplementation. The combination therapy of thiazide and supplemental hydration markedly reduced both renal calcium excretion and urinary calcium concentration from 0.4-0.7 to less than 0.1 mg/mg (urinary calcium/creatinine ratio) and from 10-15 to 3-5 mg/dl (urinary calcium concentration), respectively. This therapy stopped the progression of renal calcification during the follow-up period. CONCLUSION: Supplemental hydration should be considered essential for the following reasons: (1) calcium supplementation activates the CaSR in the kidney and suppresses renal urinary concentrating ability, (2) the thiazide has a diuretic effect, (3) as calcium supplementation increases renal calcium excretion, the supplemental hydration decreases urinary calcium concentration by increasing urinary volume, thereby diminishing the risk of intratubular crystallization of calcium ion.

Cerebral alterations in a MPTP-mouse model of Parkinson's disease--an immunocytochemical study.

We investigated the immunohistochemical alterations of neuronal nitric oxide synthase (nNOS), endothelial NOS (eNOS), tyrosine hydroxylase (TH), microtubule-associated protein 2a,b (MAP 2), glial fibrillary acidic protein (GFAP), parvalbumin (PV), and dopamine transporter (DAT) in the striatum and substantia nigra following the application of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) in mice. TH-, MAP 2- and DAT-immunoreactive cells were decreased gradually in the striatum and substantia nigra from 1 day up to 7 days after MPTP treatment, as well as the reduction of the striatal dopamine, DOPAC and HVA content. The number of GFAP-immunoreactive astrocytes increased gradually in the striatum and substantia nigra from 1 day up to 7 days after MPTP treatment. Striatal nNOS-immunoreactive cells were unchanged in MPTP-treated mice. In the substantia nigra, intense immunoreactivity of nNOS-positive cells increased 5 hr after MPTP treatment. Thereafter, the immunoreactivity of nNOS-positive cells decreased gradually from 1 day up to 7 days after MPTP treatment. eNOS-immunopositive cells were unchanged in the striatum and substantia nigra. These results demonstrate that nNOS may play a key role in the development of MPTP neurotoxicity. Our findings also indicate that MPTP can cause the functional damage of interneurons in the substantia nigra, but not in the striatum.

Role of dopamine transporter against MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) neurotoxicity in mice.

We investigated the alterations of dopamine transporter (DAT)-immunopositive cells against MPTP neurotoxicity, in comparison with tyrosine hydroxylase (TH)-immunopositive neurons and glial fibrillary acidic protein (GFAP)-immunopositive cells. This study showed that DAT and TH immunoreactivity was decreased gradually in the striatum and substantia nigra of mice after MPTP treatment. The patterns of the intense TH-immunoreactive fibers and cell bodies were similar to those of DAT-immunoreactive fibers and cell bodies in the striatum and substantia nigra of mice after MPTP treatment. In contrast, GFAP immunoreactivity was increased gradually in the striatum and substantia nigra after MPTP treatment. In our double-labeled immunostaining with anti-DAT and anti-GFAP antibodies, DAT immunoreactivity was observed only in the nigral dopaminergic neurons, but not in the reactive astrocytes. The present results provide further evidence that the functional damage of DAT may precede dopaminergic neuronal death after MPTP treatment, although the decrease in the number of TH-immunopositive neurons was more pronounced than that in the number of DAT-immunopositive neurons. Furthermore, our findings demonstrate that MPTP can selectively injure the dopaminergic neurons which DAT proteins are predominantly distributed on the striatum and substantia nigra. The results provide beneficial information for MPTP-induced neurodegeneration of the nigrostriatal dopaminergic neuronal pathway.

Role of nitric oxide synthase against MPTP neurotoxicity in mice.

1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) causes nigrostriatal dopaminergic pathway injury similar to that observed in Parkinson's disease. Many hypotheses have been proposed to explain the mechanisms underlying MPTP neurotoxicity. Previous work showed that the inhibitor of neuronal nitric oxide synthase (nNOS) might produce protection against MPTP-induced dopaminergic toxicity. To exactly test the role of NO in MPTP neurotoxicity, we examined the effect of nNOS inhibitor 7-nitroindazole, in comparison with that of nonselective NOS inhibitor (L-NAME), immunosuppressant (FK-506), monoamine oxidase (MAO) inhibitors (clorgyline and pargyline), N-methyl-D-aspartate receptor antagonist (MK-801) and Ca2+ antagonist (amlodipine). Among seven compounds, 7-nitroindazole produced dose-dependent protection against MPTP-induced depletion of striatal dopamine and its metabolite 3,4-dihydroxyphenyl acetic acid (DOPAC) in mice. Clorgyline and pargyline also showed a significant effect on MPTP-induced dopamine depletion in the mouse striatum. However, both compounds did not protect against MPTP-induced depletion of striatal DOPAC Our immunohistological study with tyrosine hydroxylase (TH) and microtuble-associated protein 2 (MAP 2) showed that 7-nitroindazole or pargyline can protect against MPTP-induced depletion of TH and MAP 2 immunostained neurons in the substantia nigra. Furthermore, these compounds reduced a marked increase in GFAP-positive astrocytes of the mouse striatum after MPTP treatments. The present study demonstrates that nNOS inhibitor 7-nitroindazole as well as MAO inhibitors clorgyline and pargyline can produce dose-dependent neuroprotection against the dopaminergic neurotoxicity of MPTP. However, nonselective NOS inhibitor L-NAME, immunosuppressant FK-506, NMDA receptor antagonist MK-801 and Ca2+ antagonist amlodipine did not show a beneficial effect on MPTP neurotoxicity.

Therapeutic effect of neuronal nitric oxide synthase inhibitor (7-nitroindazole) against MPTP neurotoxicity in mice.

Effects of neuronal nitric oxide synthase (nNOS) inhibitor (7-nitroindazole), nonselective NOS inhibitor (N(G)-nitro-L-arginine methyl ester; L-NAME), and monoamine oxidase inhibitor (pargyline) were studied on 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-treated mice. The mice received four intraperitoneal injections of MPTP at 1-h intervals. A significant depletion in dopamine and DOPAC concentration was observed in the striatum from 1 day after MPTP treatment. The pretreatment of 7-nitroindazole and pargyline, but not L-NAME, dose-dependently protected against MPTP-induced depletion in dopamine content 3 days after MPTP treatment. Our histochemical study also showed that 7-nitroindazole and pargyline can prevent a marked decrease in the nigral cells and a marked increase in astrocytes in striatum 7 days after MPTP treatment. The protective effect of 7-nitroindazole against MPTP-induced dopamine and DOPAC depletion in the striatum was not attenuated by intraperitoneal pretreatment with L-arginine. Furthermore, the posttreatment of 7-nitroindazole or pargyline protected against MPTP-induced depletion of dopamine content. These results demonstrate that the protective mechanism by which 7-nitroindazole counteracts MPTP neurotoxicity in mice may be due not only to inhibition of nNOS, but also to MAO-B inhibition. Furthermore, our study suggests that the posttreatment of 7-nitroindazole and pargyline can prevent a significant decrease in dopamine levels in the striatum of MPTP-treated mice. These findings have important implications for the therapeutic time window and choice of nNOS or MAO inhibitors in patients with Parkinson's disease.

Aldosterone synthase gene (CYP11B2) C-334T polymorphism, ambulatory blood pressure and nocturnal decline in blood pressure in the general Japanese population: the Ohasama Study.

OBJECTIVE: The C-344T polymorphism in the 5'-flanking region of the aldosterone synthase (CYP11B2) gene has been suggested to be associated with hypertension and disturbed circadian blood pressure (BP) rhythm through its effect on aldosterone synthesis. However, previous findings on this topic have been inconsistent. DESIGN: A cross-sectional study. SUBJECTS AND METHODS: We investigated the CYP11B2 C-344T genotype in 802 subjects, aged 40 and over, in a Japanese community, who gave written informed consent and were monitored for 24 h ambulatory BP. RESULTS: The frequencies of the CC, CT, and TT genotypes in these Japanese subjects were 0.14, 0.44, and 0.42, showing a higher frequency of the T allele (0.64) than in Caucasians. Although there was no significant difference in 24 h ambulatory BP levels among the genotypes, the nocturnal decline in BP was significantly greater in the CC homozygous subjects than in other subjects (P = 0.0065 for systolic and P = 0.031 for diastolic decline in nocturnal BP). Detailed analyses demonstrated that this association was significant only in aged (60 years and over) or male subjects. The prevalence of previous cardiovascular disease was significantly less in these subjects with the CC genotype than in those with the TC and TT genotypes, although age, body mass index, male gender, smoking, use of alcohol and antihypertensive medication did not differ among the three genotypes. There was no significant difference among the three genotypes in biochemical and hormonal parameters. CONCLUSION: Although the C-344 T polymorphism of CYP11B2 did not directly influence the level of 24 h BP, the CC genotype was associated with decreased nocturnal BP in elderly or male Japanese. Since prevalence of previous cardiovascular disease was significantly less in homozygous CC subjects, greater nocturnal BP decline in this genotype appears to be beneficial in the circadian BP rhythm.

Limited urinary concentration and damaged tubules in rats with a syngeneic kidney graft.

BACKGROUND: The underlying mechanisms of renal transplant dysfunction are poorly understood. There is little information on tubular function in kidney grafts. The cDNAs encoding kidney-specific cell surface proteins required for renal reabsorption of sodium (sodium cotransporter in thick ascending limb of Henle, rBSC1) and water (apical water channel in collecting duct, AQP2) have been recently identified. Since transcripts of these proteins are up-regulated in dehydration in association with maximal concentration of urine, we examined urinary concentrating ability and expression levels of mRNA of these proteins in kidney isografts. METHODS: Male Sprague-Dawley rats underwent syngeneic renal transplantation or unilateral nephrectomy (UNX) and were deprived of water for 24 hours at six weeks after the operation when histological and functional compensation of the intact kidney was complete. Blood and urinary samples were collected before and after dehydration. The amount of rBSC1 or AQP2 mRNA was measured using competitive polymerase chain reaction (PCR) by inducing a point mutation at the middle of PCR product for rBSC1 or by deleting 180 bp from 780 bp PCR product for AQP2, respectively. The protein expression was examined by Western blot analysis. RESULTS: Both groups of rats demonstrated the same levels of compensatory renal hypertrophy (approximately 60% weight increase) and plasma creatinine values. Histological examination revealed enlarged glomeruli and tubules, but no findings of ischemic damage, such as tubular atrophy or interstitial changes. Urinary concentration was noted in the UNX rats but not in rats with kidney grafts. Competitive PCR demonstrated that dehydration did not increase rBSC1 and AQP2 transcripts in rats with kidney transplantation. Immunoblot analysis confirmed that the marked increase of both rBSC1 and AQP2 proteins was noted only in the remnant kidney of dehydrated rats. CONCLUSIONS: Rats with kidney isografts have a limited capacity to concentrate urine and, at the same time, fail to increase rBSC1 and AQP2 transcripts. This suggests that there is a prolonged damage of renal tubules by ischemia or denervation of the donor kidney, both of which are inevitable in the transplantation procedure.

Predictive values of automated blood pressure measurement: what can we learn from the Japanese population - the Ohasama study.

BACKGROUND: Measurements of ambulatory blood pressure (ABP) and of home blood pressure (HBP) as an adjunct to casual/clinic blood pressure (CBP) measurements are currently widely used for the diagnosis and treatment of hypertension. We have monitored a rural cohort of people from the population of Ohasama, Japan, with respect to their prognosis and have previously reported that ABP and HBP are superior to CBP for the prediction of cardiovascular mortality. One reason that CBP is a poor predictor of prognosis is that it incorporates several biases, including the white-coat effect. METHODS AND RESULTS: We examined the prognostic significance of white-coat hypertension for mortality and found that the relative hazard for the overall mortality of patients with white-coat hypertension was significantly lower than that for true hypertension. Short-term blood pressure variability has recently attracted attention as a cause of target-organ damage and cardiovascular complications. Our results confirmed that short-term blood pressure variability (as measured every 30 min) was independently associated with cardiovascular mortality. In addition, research has recently focused on isolated systolic hypertension and pulse pressure as independent risk factors for poor cardiovascular prognosis. The Ohasama study also clearly demonstrated that isolated systolic hypertension and increased pulse pressure, as assessed by HBP, were associated with an increase in the risk of cardiovascular mortality. Circadian blood pressure variation is characterized by a diurnal elevation and a nocturnal decline in blood pressure. We therefore compared morbidity from stroke between dippers (subjects who show an ordinal nocturnal dipping of blood pressure) and non-dippers (those with a diminished nocturnal dipping or nocturnal elevation of blood pressure [inverted dippers]) in the Ohasama study. The incidence of stroke increased with an increased length of observation in dippers using antihypertensive medication but not in non-dippers using antihypertensive medication. In contrast, the relative hazard for mortality increased in non-dippers and inverted dippers. These results suggest a cause-and-effect relationship for both dippers and non-dippers. CONCLUSION: The Ohasama study showed that the level and variability of hypertension as assessed by ABP and HBP are independent predictors of cardiovascular mortality. It also demonstrated an independent association between the prognosis of hypertension and each component of ABP and HBP, indicating the prognostic significance of these blood pressure measurements.

Prognostic significance of blood pressure and heart rate variabilities: the Ohasama study.

To investigate the association between cardiovascular mortality and short-term variabilities in blood pressure and heart rate, we performed a long-term prospective study of ambulatory blood pressure monitoring in Ohasama, Japan, starting in 1987. We obtained ambulatory blood pressure and heart rate in 1542 subjects >/=40 years of age. Blood pressure and heart rate variabilities were estimated as a standard deviation measured every 30 minutes by ambulatory monitoring. There were 67 cardiovascular deaths during the follow-up period (mean=8.5 years). The Cox proportional hazards model, adjusted for possible confounding factors, demonstrated a significant increase in cardiovascular mortality, with an increase in daytime systolic ambulatory blood pressure variability. A similar trend was observed in daytime diastolic and nighttime ambulatory blood pressures. Cardiovascular mortality rate increased linearly, with a decrease in daytime heart rate variability. Subjects in whom the daytime systolic ambulatory blood pressure variability was larger than third quintile and the daytime heart rate variability was lower than the mean-SD were at extremely high risk of cardiovascular mortality. The blood pressure and heart rate variabilities obtained every 30 minutes by ambulatory blood pressure monitoring were independent predictors for cardiovascular mortality in the general population.

Japanese individuals do not harbor the T594M mutation but do have the P592S mutation in the C-terminus of the beta-subunit of the epithelial sodium channel: the Ohasama study.

OBJECTIVE: To assess the implications of polymorphisms of the amiloride-sensitive epithelial sodium channel in essential hypertension in the Japanese population by determining the incidence of the T594M mutation in the , subunit of the epithelial sodium channel, and by screening the C-terminus of the epithelial sodium channel. METHODS: Single-strand confirmational polymorphism (SSCP) analysis using two sets of primers which cover the last two-thirds of the last exon coding the B epithelial sodium channel and modification of a specific enzyme restriction site (NlaIII) for the T594M mutation were performed on 803 Japanese subjects. They were randomly selected from the study participants representative of a general population of Ohasama, Japan, who measured their home blood pressure. Polymerase chain reaction (PCR) products presenting a shift in SSCP gel, as well as controls, were directly sequenced by autoanalyser to identify the mutation. RESULTS: SSCP analysis identified altered migration in five subjects. Four SSCP variants found by sequencing were heterogeneous for the P592S (CCT to TCT) mutation conserving the PY motif, although it was not significantly associated with either home or casual blood pressure values. The resting polymorphism was at codon Thr 594, leading to no change in the amino acid sequence (ACG to ACA). None of the PCR products were modified by NlaIII, indicating the absence of the T594M mutation. CONCLUSIONS: The epithelial sodium channel variants at the C-terminus are not involved in the common form of essential hypertension in Japanese.

Cardiac infarcts increase sodium transporter transcripts (rBSC1) in the thick ascending limb of Henle.

BACKGROUND: Enhanced expression of the kidney-specific sodium transporter, rBSC1, in the thick ascending limb of Henle (TAL) and of the renal water channel, aquaporin-2 (AQP2), in collecting duct has been identified in rats with congestive heart failure (CHF) as a cause for enhanced sodium and water retention in this condition. However, the mechanism of impaired urinary sodium excretion observed even in rats with mild cardiac dysfunction remains unknown. METHODS: Male Sprague-Dawley rats with myocardial infarctions measuring 15 to 30% of the left ventricular circumference with no overt CHF were prepared. We measured the amount of rBSC1 or AQP2 mRNA using competitive polymerase chain reaction (PCR) by inducing a point mutation at the middle of the PCR product for rBSC1 or by deleting 180 bp from the 760 bp PCR product for AQP2, respectively. The results were confirmed by in situ hybridization. rBSC1 protein expression was examined by immunohistochemistry and Western blot analysis using a specific antibody against rBSC1. RESULTS: Although plasma renin activity was slightly elevated in rats with myocardial infarction (MI), no significant differences in lung weight or plasma concentrations for aldosterone and atrial natriuretic peptide were observed between control rats and MI rats. Competitive PCR showed a significant increase in rBSC1 mRNA in the renal outer medulla and cortex of MI rats, which was confirmed by in situ hybridization. However, the AQP2 mRNA of these rats remained unchanged throughout the kidney. Renin-angiotensin II blockade by oral captopril administration did not influence the alteration in rBSC1 mRNA induced by myocardial infarction. Immunohistochemistry and Western blots showed the enhanced expression of rBSC1 protein in TAL of rats with small to moderate cardiac infarcts. CONCLUSIONS: rBSC1 is up-regulated even in rats with small to moderate myocardial infarctions, which may enhance the sodium transport in the TAL in this pathophysiologic condition.

Topographic distribution of aquaporin 2 mRNA in the kidney of dehydrated rats.

BACKGROUND: Stimulation of arginine vasopressin results in an immediate redistribution of water channels (aquaporin 2; AQP2) in the apical membrane of the collecting ducts, leading to water reabsorption. Water restriction for >/=24 h increases AQP2 proteins in the whole collecting duct which is highest in the inner medulla of the kidney, indicating that dehydration enhances synthesis of this protein. Although increased expression of AQP2 mRNA under this condition has been reported, the increased ratio of mRNA expression in the three regions of the kidney, cortex, outer medulla, and inner medulla, during the dehydration is still unclear. METHODS: We investigated the AQP2 transcripts using male Sprague-Dawley rats deprived of water for 24 h. Mimic cDNA for competitive polymerase chain reaction (PCR) was constructed by deleting 180 bp at the middle of a 780-bp partial PCR product for rat AQP2 cDNA. In situ hybridization of the kidney and Northern blotting of inner medulla were performed using a 60-bp oligo-cDNA probe which identified rat AQP2 transcripts in the collecting duct. RESULTS: Dehydration resulted in a significant increase in plasma osmolality and arginine vasopressin concentration and urinary osmolality. Competitive PCR demonstrated that dehydration increased AQP2 transcripts in all parts of the kidney, but was highest in the inner medulla. Northern blotting confirmed the high increased rate of AQP2 transcription in the inner medulla. In situ hybridization showed markedly intensified signals in the inner medulla of dehydrated rats. CONCLUSIONS: Our data indicate that dehydration increases the abundance of AQP2 transcripts which may be closely associated with enhancement in AQP2 protein synthesis reported previously. This topographically variable increase in transcription is considered to be one of the mechanisms involved in long-term regulation of water permeability in the collecting duct.

Relationships among blood pressures obtained using different measurement methods in the general population of Ohasama, Japan.

To examine the relationships between casual, ambulatory and home blood pressure measurements in the general population, these measurements were obtained in 1,695 of 3,744 subjects aged 20 yr or older in Ohasama, Japan. Of these 1,695 subjects, 1,207 measured their home blood pressure more than 14 times in each of the morning and evening (881 untreated subjects including normotensives and untreated hypertensives, 56.4 +/- 11.5 yr of age; 326 treated subjects, 66.0 +/- 9.2 yr of age). We analyzed data in these 1,207 subjects, examining the distribution of each measurement, the relationships among measurements, and the factors affecting the blood pressure differences among the measurements. For systolic pressure, the casual measurement was the highest among the methods examined. The daytime ambulatory measurement was significantly higher than morning and evening home measurements. Morning home measurements were significantly higher than those in the evening. For diastolic pressure, however, the morning home measurement was the highest among the methods examined. Short-term pressure variability (standard deviation and variation coefficient of ambulatory measurements) was greater than long-term pressure variability (standard deviation and variation coefficient of home measurements). The pressure variability in treated subjects was greater than that in untreated subjects. The correlation between casual pressure and the other pressures was not as strong (r<0.567). Among the relationships between ambulatory and home measurements, the strongest correlation was observed between the 24-h ambulatory measurement and the morning home measurement (r=0.738) in untreated subjects. The morning home measurement was highly correlated with the evening home measurement (r>0.814). The differences among the methods examined were affected by blood pressure level and age. It should be noted that in elderly and treated subjects, blood pressure measurement using one method does not necessarily correlate with that obtained using the other methods. This information is useful for the estimation of the value of one type of blood pressure measurement from values obtained with other methods.

[Initiation of hematopoietic recovery by recombinant human granulocyte-macrophage colony-stimulating factor in a case of severe aplastic anemia induced by gold salt].

A 65-year-old female with severe aplastic anemia induced by gold salt, whose hematopoietic recovery was initiated by rhGM-CSF therapy, was reported. The patient has been given a total of 500 mg of gold-sodium thiomalate for treatment of her rheumatoid arthritis. Two months after the final administration of it, she was admitted to our hospital with complaints of palpitation and shortness of breath. The hemogulobin was 5.9 g/dl, the platelet count was 0.5 x 10(4)/microliter, and the leukocyte count was 800/microliters with 19% neutrophils. Her bone marrow showed aplasia, and both of Ham and sugar-water tests were positive. Three times of bolus-methylprednisolone treatment, with or without methenolone acetate, resulted in no definite improvement of peripheral pancytopenia and marrow aplasia. Subsequent subcutaneous rhGM-CSF, 300 micrograms daily for 28 days with oral prednisolone 5 mg and methenolone acetate 40 mg daily, initiated hematopoietic recovery of all three cell lineages in both peripheral blood and bone marrow. The same doses of prednisolone and methenolone acetate were continued after rhGM-CSF administration, and three months later peripheral cytopenia and positive Ham and sugar-water tests disappeared completely.