Effect of hyperkalemia on insulin secretion.

The effect of hyperkalemia on insulin secretion remains undefined. We evaluated portal and peripheral insulin levels in anesthetized dogs after infusions of KCl. The mean maximal increase in peripheral plasma potassium at infusion rates of 0.2 mEq/kg/h was 0.68 +/- 0.20 mEq/l. There were no significant increases in either portal or peripheral insulin levels. In contrast, in six dogs whose plasma potassium concentration increased in each case by more than 2.0 mEq/l (infusion rate of 0.5 mEq/kg/h), portal insulin levels increased fivefold (p less than 0.05). We concluded that only marked increases in plasma potassium concentration stimulate pancreatic insulin secretion.

Effect of hypertonic versus isotonic sodium bicarbonate on plasma potassium concentration in patients with end-stage renal disease.

The purpose of the study was to evaluate the potassium-lowering effect of hypertonic versus isotonic sodium bicarbonate (NaHCO3) in patients with end-stage renal disease (ESRD) receiving chronic maintenance hemodialysis. Immediately prior to dialysis, we infused isotonic (1.4%, 150 mEq/l) NaHCO3 in H2O (1 mEq/kg body weight over 2 h) to 10 patients with ESRD. Blood was drawn in heparinized tubes, without the use of a tourniquet, from the angioaccess for Na, K, pH, PCO2, HCO3, and osmolality at baseline (x 3) and after 10, 20, 40, 60, 90, 120, and 180 min of infusion. All patients were acidotic (HCO3 13-21 mEq/l, pH 7.25-7.38) prior to the study. In these patients, plasma HCO3 increased by an average of 3 mEq/l, and plasma K decreased by 0.35 mEq/l at 180 min. Plasma osmolality did not change. In 8 patients, a bolus of hypertonic (8.4%, 1,000 mEq/l) NaHCO3 (1 mEq/kg body weight over 5 min) tended to cause a transient increase in plasma HCO3, an increase in plasma osmolality, and minor changes in the K levels (an initial small and transient albeit significant decrease, followed by a tendency to increase). Finally, plasma K tended to increase in patients receiving infusions of either isotonic (n = 6) or hypertonic (n = 6) sodium chloride. Our data do not support the efficacy of the common practice of administering NaHCO3 for the emergency treatment of hyperkalemia in patients with ESRD receiving maintenance dialysis.

Influence of magnesium sulfate-induced hypermagnesemia on the anion gap: role of hypersulfatemia.

Although hypermagnesemia purportedly lowers the anion gap (AG), we have shown previously that increases in the serum concentration of the unmeasured cation (UC) Mg due to therapeutic infusion of MgSO4 are not associated with AG reduction. To assess our hypothesis that increases in serum SO4 (unmeasured anion, UA) offset the effect of elevated serum Mg on the AG, we prospectively studied 11 patients receiving MgSO4 intravenously for toxemia of pregnancy. After 6 h of MgSO4 infusion, serum Mg increased by 2.1 +/- 0.2 (SE) mEq/l (p less than 0.001) without a significant decrease in the AG. Concomitantly, serum SO4 increased by 1.4 +/- 0.2 mEq/l. Comparison of the renal handling of SO4 versus Mg showed a higher fractional excretion of the former, probably accounting in part for the smaller increment of serum SO4 than of Mg. Comparison of the change in serum SO4 minus that of Mg indicated that, on the average, 70% of the observed 1.0 +/- 0.7 mEq/l reduction in AG was accounted for by the observed changes in the two pertinent unmeasured ions. A small decrement in serum Ca probably was a quantitatively minor factor tending to obviate a greater decrease in AG. We conclude that hypersulfatemia attenuates the reduction in AG that would otherwise accompany MgSO4-induced hypermagnesemia.

Effect of indomethacin on acute potassium tolerance.

Nonsteroidal anti-inflammatory drugs are believed to impair potassium tolerance in both humans and experimental animals. We evaluated plasma potassium response to an acute potassium chloride load (75 microEq/100 gm body wt) in rats pretreated with indomethacin (10 mg/kg body wt). The increment in plasma potassium concentration in the indomethacin-treated group was significantly higher than that in the control group. In a subset of anuric animals treated with indomethacin, the change in plasma potassium concentration after potassium chloride infusion was similar to that in controls. We conclude that indomethacin disrupts acute potassium tolerance. The abnormality may be related to renal rather than extrarenal mechanisms.

Can beta-hydroxybutyrate be detected at the bedside by in vitro oxidation with hydrogen peroxide.

The diagnosis of ketoacidosis with an inordinately high plasma and urinary concentration ratio of beta-hydroxybutyrate (beta-OHB) to acetoacetate (AcAc) is difficult, because only AcAc and acetone react with the diagnostic reagents used clinically to detect ketones. The purpose of this study was to assess the validity of the claim that beta-OHB can be identified with a simple modification of the usual bedside test for ketones, using hydrogen peroxide (H2O2) and Ketostix (Ames Division, Miles Laboratories, Inc., Elkhart, Indiana). Unfortunately, the lowest detectable concentration of urinary beta-OHB was 50 mmol/L, and serum beta-OHB could not be detected at levels less than 100 mmol/L, a clinically irrelevant level. The relative insensitivity, the inapplicability to serum, and the potential hazard of the routine use of 30% H2O2 by practicing physicians or houseofficers render the method of limited value.

Impaired glucagon-stimulated glucose output in livers of acutely uremic rats.

The role of glucagon in the pathogenesis of abnormalities of glucose metabolism associated with renal failure remains undefined. We have evaluated glucagon-stimulated glucose and cyclic AMP output and amino acid uptake in isolated perfused livers of rats with experimentally-induced ARF and sham-operated controls. ARF animals exhibited azotemia, hyperglycemia, hyperinsulinemia, and hyperglucagonemia. During stimulation with physiologic (3 X 10-10M) or supraphysiologic (3 X 10-8M) glucagon concentrations, glucose output was lower in livers of ARF rats than in those of controls, whereas cyclic AMP responses were similar or exceeded those of controls. Hepatic glycogen content was lower in rats with ARF and the stores were exhausted at the end of perfusions. Additional studies in livers of fasted animals revealed no significant differences in glucose output or amino acid uptake between ARF and control livers perfused with physiologic levels of glucagon. These experiments suggest that the decreased glucagon-stimulated glucose output in isolated perfused livers in acutely uremic rats is due primarily to glycogen depletion rather than to impaired gluconeogenesis. Normal or increased cyclic AMP responses to glucagon suggests intactness of the hormone receptor-adenylate cyclase.

Functional adaptation to reduction in renal mass: renal handling of amino acids by isolated perfused remnant rat kidneys.

To date, the renal handling of amino acids by remnant kidneys remains undefined. We have determined the renal handling of eight amino acids using the isolated perfused rat kidney. 6 normal and 22 partially infarcted rat kidneys (16 stage III [contralateral kidney removed], and 6 stage II [contralateral kidney left intact] were evaluated at perfusate amino acid concentrations approximately ten times normal plasma levels. Despite the reduction in glomerular filtration rate, the urinary excretion of most amino acids in remnant kidneys tended to exceed that of controls. Fractional amino acid excretion by both stage II and III kidneys tended to be or was higher than that of controls. The findings indicate that the fractional reabsorption of amino acids by residual nephrons of remnant kidneys is decreased. Our observations suggest that the changes are unrelated to a functional adaptation to the uremic environment.

Urea synthesis by perfused rat liver in experimental uremia.

Urea synthesis was examined in experimental uremia using the isolated perfused rat liver in order to assure strict control of substrate (NH4Cl) presented to the liver. Acute uremia was created in female Sprague-Dawley rats by bilateral nephrectomy (n = 7) 48 h prior to studies. Chronic uremia (8--14 weeks) was produced by right nephrectomy and segmental infarction of the left kidney in 7 rats. At infusion rates of NH4Cl (8.3 mumol/min) which resulted in prehepatic perfusate ammonia levels approximately twice the previously described Km value, livers of chronically uremic rats had slightly higher rates of urea production than controls (controls: 0.41 +/- 0.03; chronic uremia: 0.54 +/- 0.04 mumol/min/g of wet liver weight; p less than 0.02). In acute uremia, urea production was higher (0.66 +/- 0.05 mumol/min/g) than in sham-operated rats (0.59 +/- 0.05 mumol/min/g) but the differences did not achieve statistical significance. Simultaneously performed taurocholate transport studies did not reveal significant functional differences between the livers of uremic and control animals. The data suggest that urea production by livers of uremic rats is increased when compared to that of control animals.

Metabolism of arginine by the isolated perfused rat kidney.

In order to evaluate the renal contribution to the metabolism of arginine, we have evaluated its biosynthesis and catabolism in the isolated perfused rat kidney. The kidneys of eight male Sprague-Dawley rats were perfused with Krebs-Ringer-bicarbonate buffer containing albumin and amino acids. Twenty-five muCi of L-[guanidino-14C]arginine or 25 muCi L-[guanidino-14C]citrulline were added to the system and radiochromatograms of the perfusate were obtained at 0, 30, 60, and 90 min. Perfusate levels of urea, creatine, and guanidine derivatives were measured with high-pressure liquid chromatography. During perfusion there was net utilization of arginine and net production of creatine, guanidinoacetic acid (GAA) and guanidinosuccinic acid (GSA). The guanidino carbon of arginine was incorporated by the kidney into urea, creatine GSA, GAA, and guanidinobutyric acid. The production of 14C-labeled urea from L-[guanidino-14C]citrulline was substantially lower than that previously demonstrated in the liver, while that of arginine was approximately 20 times greater. These studies demonstrate the important contribution of the kidney to the synthesis and metabolism of arginine.

Effect of acute uremia on arginine metabolism and urea and guanidino acid production by perfused rat liver.

Since arginine is a precursor of urea and other guanidino derivatives, we have evaluated its metabolism in acute uremia using the isolated perfused rat liver. Female Sprague-Dawley rats underwent bilateral nephrectomy (n = 5) or sham operation (n = 5) 48 h prior to liver perfusion. Fifty microCi of L-[guanidino 14C] arginine and unlabelled arginine and aspartic acid were added to the recycling perfusate 15 min prior to liver perfusion. Perfusate concentrations of urea and other guanidino derivatives were measured with high-pressure liquid chromatography. After the initial 30 min of perfusion, net uptake of arginine was lower, and net release of guanidino-succinic acid (GSA) was higher in the livers of acutely uremic rats. Net release of urea was also higher in uremia but the results did not achieve statistical significance. In uremia, the percent conversion of 14C arginine to 14C urea was significantly higher (79 +/- 5 [SE]%) than in controls (58 +/- 7%). These results demonstrate increased GSA production by livers of acutely uremic rats and suggest that acute uremia may be associated with increased arginine utilization and increased production of urea.