Left ventricular hypertrophy in renal disease: beyond preload and afterload

To explain ventricular concentric and/or eccentric hypertrophy in chronic kidney disease, past studies suggested that this was the result of increased preload and/or afterload. Using a renal ablation model of the mouse with documented absence of hypertension, Siedlecki et al. provide evidence for the involvement of the mammalian target of rapamycin (mTOR) pathway. This suggests that load-independent primary stimuli trigger or contribute to ventricular hypertrophy and fibrosis in uremia

Combination therapy with ACE inhibitors and angiotensin II receptor blockers to halt progression of chronic renal disease: Pathophysiology and indications

Combination therapy with ACE inhibitors and angiotensin II receptor blockers to halt progression of chronic renal disease: Pathophysiology and indications. It is no a secret that we are confronted by an alarmingly increasing number of patients with progressive renal disease. There is ample evidence for the notion that angiotensin II (Ang II) is a major culprit in progression. The vasopeptide Ang II turned out to have also multiple nonhemodynamic pathophysiologic actions on the kidney, including proinflammatory and profibrogenic effects. Diverse complex Ang II generating systems have been identified, including specifically local tissue-specific renin-angiotensin systems (RAS). For example, proximal tubular cells have all components required for a functional RAS capable of synthesizing Ang II. On the other hand, Ang II is not the only effector of the RAS and other peptides generated by the RAS influence renal function and structure as well. Moreover, the discoveries that Ang II can be generated by enzymes other than angiotensin-converting enzyme (ACE) and that Ang II and other RAS derived peptides bind to various receptors with different functional consequences have further added to the complexity of this system. Several major clinical trials have clearly shown that ACE inhibitor treatment slows the progression of renal diseases, including in diabetic nephropathy. Well-controlled studies demonstrated that this effect is in part independent of blood pressure control. More recently, with Ang II type 1 receptor (AT1) receptor antagonists a similarly protective effect on renal function was seen in patients with type 2 diabetes. Neither ACE inhibitor treatment nor AT1 receptor blockade completely abrogate progression of renal disease. A recently introduced novel therapeutic approach is combination treatment comprising both ACE inhibitor and AT1 receptor antagonists. The rationale for this approach is based on several considerations. Small-scale clinical studies, mainly of crossover design, documented that combination therapy is more potent in reducing proteinuria in patients with different chronic renal diseases. Blood pressure as an important confounder was, however, significantly lower in the majority of this studies in the combination treatment arms compared to the respective monotherapies. In a recent prospective study Japanese authors avoided this confounder and demonstrated that combination therapy reduced hard end-points (end stage renal failure or doubling of serum creatinine concentration) by 50% compared to the respective monotherapies. This effect could not be explained by a more pronounced reduction of blood pressure in the combination therapy group. Although these results are encouraging, administration of combination therapy should be reserved currently to special high risk groups. Further studies are necessary to confirm these promising results. It is possible that combination therapy may increase the risk of hyperkalemia, particularly when with coadministered with medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) or spironolactone. In our opinion patients with proteinuria >1 g/day despite optimal blood pressure control under RAS-blocking monotherapy are a high-risk group which will presumably benefit from combination therapy

Osteodystrophy in the millennium

Osteodystrophy in the millennium. Despite three decades of intensive research on the derangements of calcium phosphate metabolism of renal failure, several unresolved issues are still with us at the turn of the millennium: poor control of hyperphosphatemia, relative inefficacy of active vitamin D to prevent progressive parathyroid hyperplasia, and persistence of bone disease despite lowering of parathyroid hormone (PTH) and administration of active vitamin D. Although predictions are problematic, it is not unreasonable to hope that, barring unforeseen side effects, calcimimetics will prove to be valuable for suppressing or even preventing hyperparathyroidism, thus potentially replacing, at least in part, active vitamin D. There is also reason to hope that more effective phosphate binders with fewer side effects will become available and that controlled studies will provide a rationale for the administration of estrogens to dialyzed women. As regards understanding the pathological mechanisms, one can anticipate that the disturbances leading to autonomous growth of parathyroid cells will be elucidated and the signals involved in osteoclast/osteoblast differentiation pathways and osteoclast/osteoblast coupling will be clarified, with obvious impact on patient management

Vascular calcification: A stiff challenge for the nephrologist Does preventing bone disease cause arterial disease

Vascular calcification: A stiff challenge for the nephrologists—Does preventing bone disease cause arterial disease? There has been an explosion of interest in vascular calcification in the last 5 years. Four key “germinal” findings have fallen onto very fertile soil. First, on the background of an increasing cardiovascular disease burden it has been found that at least cross-sectionally, and in a limited fashion prospectively, achieved dialysis plasma phosphate levels are linked to all-cause and cardiovascular mortality. Second, there are increasing reports of calcific uremic arteriolopathy in Australia and the United States. Third, we know know that the mechanical properties of the carotid artery, and the aorta, have a profound influence on survival for dialysis patients. Vascular calcification itself (as assessed by x-ray films and ultrasound) has been linked to aortic stiffness. Fourth, increasing numbers of studies are showing extremely extensive coronary artery calcification (CAC) in dialysis patients, even at a young age. From these apparently unlinked observations the following assertion has been posited—that in the widespread (over) use of calcium-containing oral phosphate binders (OPB) to prevent uremic osteodystrophy in our dialysis population we have unwittingly accelerated widespread uremic vasculopathy and thereby contributed to premature cardiovascular mortality.It is the purpose of this article to discuss vascular calcification (and particularly CAC) in dialysis patients as we understand it today. We will review the published series, with special reference to the Sevelamer Treat to Goal trial and also discuss the new Kidney Disease Outcome Quality Initiative (K-DOQI) guidelines on the use of phosphate binders in chronic kidney disease

Renal protection in diabetes: lessons from ONTARGET®

Hypertension is an important independent risk factor for renal disease. If hypertension and chronic renal disease co-exist, as is common in patients with diabetes mellitus, the risk of cardiovascular disease is heightened. The importance of rigorous blood pressure control is recognized in current guidelines, with a recommended target of office blood pressure of < 130/80 mmHg; although ambulatory blood pressure may be more appropriate in order to identify the 24-hour hypertensive burden. Even lower blood pressure may further reduce the progression of chronic kidney disease, but the incidence of cardiovascular events may increase. Albuminuria not only indicates renal damage, but is also a powerful predictor of cardiovascular morbidity and mortality at least in patients with high cardiovascular risk and potentially pre-existing vascular damage. Management of the multiple factors for renal and cardiovascular disease is mandatory in the diabetic patient. The renin-angiotensin system (RAS) plays a pivotal role in the progression of renal disease, as well as in hypertension and target-organ damage. The use of agents that target the RAS confer renoprotection in addition to antihypertensive activity. There is extensive evidence of the renoprotective effect of angiotensin II receptor blockers (ARBs), and specifically telmisartan. In addition to providing 24-hour blood pressure control, clinical studies in patients with diabetes show that telmisartan improves renal endothelial function, prevents progression from microalbuminuria to macroalbuminuria, slows the decline in glomerular filtration rate and reduces proteinuria in overt nephropathy. These effects cannot be solely attributed to blood pressure control. In contrast to other members of the ARB class, the renoprotective effect of telmisartan is not confined to the management of diabetic nephropathy; slowing the progression of albuminuria has been demonstrated in the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET®), which included diabetic and non-diabetic patients at high risk of cardiovascular events

Early increase in blood pressure and diastolic left ventricular malfunction in patients with glomerulonephritis

Early increase in blood pressure and diastolic left ventricular malfunction in patients with glomerulonephritis. In patients with diabetic nephropathy blood pressure increases progressively before the conventional threshold of normal blood pressure (140/90mm Hg) is transgressed. In patients with glomerulonephritis, no information on this point is available. To clarify this issue we sequentially examined 20 untreated patients with biopsy-proven primary chronic glomerulonephritis (GN) who had casual blood pressure below 140/90mm Hg and normal GFR by inulin clearance. Patients were compared with normotensive healthy controls who were matched for BMI, gender and age. We measured ambulatory 24-hour blood pressure (SpaceLab system), echocardiography (ASE criteria, Acuson 128 XP 10), CIn and CPAH, urinary Na excretion, PRA and insulin concentration. In patients with GN, the median 24 hour (P < 0.0005), daytime (P < 0.001) and nocturnal sleeping time (P < 0.0001) MAP values were significantly higher than in matched controls (daytime, mean 97mm Hg, 85 to 106 GN vs. 89 controls range 82 to 102; nocturnal sleeping time, mean 80.3mm Hg, 71 to 89.5 GN vs. 73 controls, range 63 to 84). Echocardiographic examination showed significantly greater posterior wall thickness (P < 0.01) and ventricular septal thickness (P < 0.003). In addition the early diastolic to late diastolic (E/A) ratio of mitral valve peak inflow velocity was significantly (P < 0.0008) lower in patients. The data point to left ventricular wall thickening accompanied by LV diastolic malfunction. The study documents elevated ambulatory blood pressure in patients with primary chronic glomerulonephritis despite normal body weight and normal GFR. This is associated with evidence of target organ damage in the heart. The findings suggest that in patients with glomerulonephritis blood pressure increases initially within the normotensive range. This observation in conjunction with evidence of early target organ changes provides an argument for early antihypertensive intervention, but controlled trials to test efficacy and safety of this proposal are necessary

Prenatal causes of kidney diseases

Deleterious environmental factors during pregnancy influence fetal development and increase therisk of cardiovascular and kidney disease in adult offspring. Undernutrition, protein restriction,excess salt, corticosteroids, or placental insufficiency disturb kidney development, causing a lowernumber of nephrons (referred to as nephron underdosing). This in turn leads to hypertension andaccelerated loss of kidney function in the adult life of the offspring. The nephron underdosingcan be observed with or without intrauterine growth restriction. A lower number of nephrons havebeen confirmed in humans with hypertension

Cuprammonium membranes stimulate interleukin 1 release and arachidonic acid metabolism in monocytes in the absence of complement

Contact of blood with foreign surfaces, specifically dialysis membranes, causes cell activation which has widely been assumed to be mediated by complement (C). To explore the possibility of C-independent activation, we examined different cell types: PMN, human monocytes and the cell lines U937 or HL60, washed human platelets and rat glomerular epithelial cell (primary) cultures (GEC), under serum-free conditions and after addition of anti-C3 F(ab)2, respectively. The monitored biological effects were release of PGE2, TXB2 or interleukin 1 and generation of O2− radicals. To further explore the mechanisms involved, phospholipid metabolism was studied by measuring IP3 and DG (14C-arachidonic or oleic acid prelabeled U937 and HL60 cells); changes of cytosolic Ca++ (Quin2 technique) were also determined. The results show that in absence of C, brief (2 min) contact with cuprammonium (CU) stimulated: (a) PGE2 release in U937 and human monocytes or GEC; (b) TXB2 release in washed platelets; (c) slow interleukin 1 release by monocytes; and (d) generation of O2− radicals in PMN. Artifacts due to endotoxin were excluded by appropriate polymyxin control experiments and by comparison of effects with those of bacterial LPS. Potential synthesis of C3 by U937 was excluded by addition of anti-C3 F(ab)2. C-independent cell activation was accompanied by increase of DG, but not IP3 (suggesting involvement of protein C kinase dependent mechanisms) and by increased cytosolic Ca++. To further explore the initial signal involved, incubations were carried out with covalently modified CU members (DEAE cellulose) and in the presence of mM concentrations of monosaccharides. Cationic modification of CU membranes reduced C-independent cell activation. Activation of arachidonic acid metabolism and increase in cytosolic calcium by unmodified CU membranes were stereospecifically inhibited by L-fucose, pointing to involvement of carbohydrates in the recognition signal

Effects of 1,25(OH)2D3 on compensatory renal growth in the growing rat

Effects of 1,25(OH)2D3 on compensatory renal growth in the growing rat. Renal compensatory growth after uninephrectomy (UNX) was examined in vitamin D replete male 100g Sprague-Dawley rats. Five days after UNX, the contralateral kidney wet weight increased by 25% with the kidney weight/body weight ratio reaching a plateau by day 7 after UNX. The early weight increase was primarily due to an increased cell number, as evaluated by a stereological technique in perfusion-fixed kidneys. Twenty pmol 1,25(OH)2D3 by daily s.c. injection increased time-averaged 1,25(OH)2D3 concentrations 3.3-fold and reduced the increment in the kidney weight of UNX pairfed rats compared to solvent UNX controls. The number of mitoses (whole kidney and different nephron segments) were significantly reduced by giving 1,25(OH)2D3 to UNX animals at different levels of food intake. The effect was also demonstrable in PTX animals on a constant infusion of exogenous PTH (100 ng/kg/hr 1,34 bPTH by osmotic minipump). The data suggest that changes of 1,25(OH)2D3 concentration within a physiologically relevant range modulate compensatory (and possibly basal) growth of the kidney