Effects in normal subjects of long-term administration of azosemide.

Azosemide is a new loop diuretic which has been shown to affect solute transport proximal to the diluting segment. We assessed the effects of chronic administration of azosemide in normal subjects on low and normal salt diets. In both, there was compensatory renin release and aldosterone secretion, but the subjects on the low sodium diet developed striking hyperuricemia and metabolic alkalosis and were symptomatic, whereas those on the normal diet compensated to the extent that there were only minor changes.     

Renal mechanism of action of rat atrial natriuretic factor.

There has been conflict as to whether crude extracts of atrial natriuretic factor increase renal solute excretion by a hemodynamic mechanism or by direct inhibition of tubular transport. To investigate this issue, seven rats were studied during a euvolemic control period and following continuous administration of pure, synthetic 24 amino acid atrial natriuretic factor. A 10-25-fold increase in urinary sodium and chloride excretion occurred with a brisk kaliuresis but little bicarbonaturia. Atrial natriuretic factor caused whole kidney glomerular filtration rate to increase from 1.17 +/- 0.04 to 1.52 +/- 0.07 ml/min (P less than 0.005). A parallel increase in single nephron glomerular filtration rate, from 34 +/- 1 to 44 +/- 2 nl/min (P less than 0.001), and from 26 +/- 1 to 37 +/- 2 nl/min (P less than 0.005) was measured at the end-proximal and early distal nephron sites, respectively. Appropriate for the higher flows were an increase in absolute proximal and loop reabsorptive rates for bicarbonate, chloride, and water, with a slight decrease in fractional solute and volume reabsorption in proximal and loop segments. To exclude the possibility that atrial natriuretic factor increased filtration rate only in anesthetized animals, eight unanesthetized rats were studied. Glomerular filtration rate increased by 45%, from 2.04 +/- 0.17 to 2.97 +/- 0.27 ml/min (P less than 0.005) without significant change in renal plasma flow, as reflected by 14C-para-aminohippurate clearance (5.4 +/- 0.5-5.6 +/- 0.9 ml/min). The clearance and micropuncture data did not preclude changes in relative blood flow distribution to or in transport by deep nephron segments. In conclusion, atrial natriuretic factor appears to increase renal solute excretion predominantly by a hemodynamic mechanism without directly inhibiting superficial tubular transport.     

Hormone receptors and sites of action in the kidney.

Identification of hormone target sites in the nephron has been achieved in part using autoradiography, and largely with microdissection and microanalysis techniques that permit quantitative measurements of hormone binding or postbinding effects in discrete nephron segments. The nephron target sites of hormones whose intracellular second messenger is known have been located by measuring their stimulatory effect on cyclic AMP or GMP production along the nephron. These hormones include arginine vasopressin, parathyroid hormone, calcitonin, and beta-adrenergic catecholamines. In contrast, the action sites of hormones whose cellular mediators are less well understood have been identified using micro modifications of conventional binding techniques scaled down to the minute (less than or equal to 1 microgram protein) amount of tissue available. In this group are aldosterone, corticosterone, insulin, angiotensin II, alpha-adrenergic catecholamines and dopamine. Atrial natriuretic peptides and glucagon have been studied with both methods. The precise localization of hormone receptors and sites of action in the functionally heterogeneous nephron is critical for understanding the interactions between the kidney and the endocrine system in fluid volume homeostasis, blood pressure control, and in biochemical and metabolic regulation.     

Renal tubular site of action of felodipine

The renal tubular site of action of felodipine was localized using renal clearance and recollection micropuncture techniques in the anesthetized rat. In initial renal clearance experiments, felodipine (2.75 nM/kg/min i.v. X 60 min) had no effect on mean arterial pressure or glomerular filtration but significantly increased urinary flow rate, sodium and potassium excretion. In subsequent recollection micropuncture experiments, felodipine decreased mean arterial pressure but did not affect renal blood flow or renal vascular resistance or glomerular filtration rate; absolute and fractional urinary excretion of sodium and water, but not potassium, were increased. Proximal tubular and loop of Henle sodium, potassium and water reabsorption were not affected but distal tubular and collecting duct sodium and water (not potassium) reabsorption were decreased by felodipine. Felodipine is a vasodilator antihypertensive agent which, in doses which decrease mean arterial pressure in normotensive rats, increases urinary flow rate and sodium excretion by inhibiting distal tubular and collecting duct sodium and water reabsorption; potassium reabsorption or excretion is not affected. As a vasodilator antihypertensive agent, felodipine possesses beneficial natriuretic rather than detrimental sodium retaining properties.     

Peripheral analgesic sites of action of anti-inflammatory drugs

Inflammatory signs and symptoms of redness, swelling, heat and pain are due to the effects of inflammatory mediators released during the inflammatory response. Depending on the type of injurious stimuli and the tissue involved, the array of mediators may differ but eicosanoids are involved in the genesis of inflammatory pain. They are responsible for the hypersensitisation of the nociceptors (allodynialhyperalgesia). The basic mechanism of analgesic action of nonsteroidal anti-inflammatory drugs results from the inhibition of prostaglandin synthesis (prostacyclin or PGE2), thus preventing nociceptor threshold lowering. Because there is a temporal hierarchy in the release of inflammatory mediators, there are several targets for the action of peripheral acting analgesics before and after the inhibition of prostaglandin synthesis. Blockade of the release and inhibition of inducible cyclooxygenase explain the analgesic action of glucocorticoids. Nimesulide also has an inhibitory action on the cascade of hypersensitising cytokines. Some analgesics, such as dipyrone, flurbiprofen or diclofenac, act directly upon ongoing inflammatory hypersensitisation. Those analgesics restore the nociceptor by stimulating the arginine/NO/cGMP/K(ATP) channel pathway.     

Digoxin toxicity: primary sites of drug action on the sympathetic nervous system.

Increases and decreases in sympathetic nerve activity have been reported to accompany digitalis-induced arrhythmias. These effects may result from drug action on various sites such as the central nervous system, ganglia, chemoreceptor or baroreceptor afferent fibers or peripheral efferent nerve fibers. The relative importance of each possible site of drug action has not been clarified. To define the involvement of some of these sites, digoxin was administered intravenously to cats in order to study its effects on activity of preganglionic splanchnic or postganglionic inferior cardiac nerves in the presence or absence of chemoreceptor and baroreceptor reflexes. In cats with intact reflexes, arrhythmic doses of digoxin had diverse effects on postganglionic activity. In some cats digoxin increased activity and in others it decreased activity. In contrast, digoxin consistently caused large progressive increases in postganglionic activity when baroreceptors and chemoreceptors had been denervated. Digoxin inhibited preganglionic nerve activity only in cats with intact reflexes but had no effect in those without chemoreceptor and baroreceptor reflexes. Thus, the afferent component of the baroreceptor reflex is the apparent site of digoxin-induced inhibition. Digoxin produced increases in activity above control only in postganglionic nerves. This finding suggests that digoxin acts on the ganglion to increase sympathetic activity. Digoxin had no discernible effect on preganglionic activity when baroreceptor and chemoreceptor afferent input had been eliminated. To test further for any subliminal drug effect in the brain, effects of intravenously administered digoxin were observed on centrally evoked submaximal responses in the splanchnic nerve. Lethal doses of digoxin had no effect on responses evoked from the medulla or the hypothalamus. Therefore, these data are not consistent with the hypothesis that a primary site of drug action is in the central nervous system. Instead, the data suggest that neural effects of digoxin result primarily from drug actions within the peripheral autonomic nervous system on sites such as the ganglion and peripheral afferent components of the baroreceptor reflex.     

Steroid synthesis inhibition by ketoconazole: sites of action

Ketoconazole is an antifungal agent that, in high doses, inhibits testicular and adrenal steroid synthesis. The ability of ketoconazole to block steroid synthesis has prompted us to use it in the treatment of advanced prostatic carcinoma. This study was designed to determine the site of steroid synthetic blockade that was induced by ketoconazole. Twelve patients with metastatic prostate carcinoma on long term high dose ketoconazole therapy were compared with 12 control volunteers. Values of serum progesterone, 17-hydroxyprogesterone, androstenedione, dehydroepiandrosterone sulphate, testosterone, and cortisol were measured in a baseline state and after Cosyntropin and human chorionic gonadotropin stimulation. Baseline data showed that serum levels of testosterone, androstenedione, and dehydroepiandrosterone sulphate were lower and that plasma progesterone, luteinizing hormone, and adrenocorticotropin were higher in the ketoconazole group. With Cosyntropin, plasma cortisol, androstenedione, and dehydroepiandrosterone sulphate increased only in the control group. With human chorionic gonadotropin, testosterone increased only in the control group. Basal 17-hydroxyprogesterone and progesterone rose after Cosyntropin only in the ketoconazole group. Following human chorionic gonadotropin, progesterone rose in the ketoconazole group but not in the control group. These results suggest that ketoconazole is a potent inhibitor of steroid synthesis. The major site of action appears to be in the inhibition of 17-20 desmolase. A moderate blockade of 17-hydroxylase may be present. There is a marked inhibition of 21- and/or 11-hydroxylase. The ability of ketoconazole to inhibit steroid synthesis should have therapeutic potential in the treatment of steroid dependent disease. Frequent high dose ketoconazole therapy can inhibit adrenal steroid synthesis, which can be important for patients undergoing stressful situations.     

Kappa-opioid receptor-mediated antinociception in the rat. II. Supraspinal in addition to spinal sites of action

This study examines whether there is a supraspinal, in addition to spinal, component to the antinociceptive actions against heat and pressure stimuli of kappa-opioid receptor agonists (U-69,593, U50,488H, bremazocine and tifluadom) as compared to mu-opioid receptor agonists (Tyr-D-Ala-Gly-NMe-Gly-ol, fentanyl and morphine) in the rat. The antinociception induced by kappa- and mu-opioids (applied s.c.) was unaffected by systemic quaternary naltrexone (50 mg/kg) revealing that it is mediated in the central nervous system. All kappa- and mu-opioids produced dose-dependent antinociception upon intrathecal application, in each case reversible by naloxone (5 mg/kg s.c.). However, intrathecal application of naloxone could only partially (by ca. 50%) antagonize the antinociception evoked by systemically applied U50,488H and morphine: this suggests sites of action in brain in addition to spinal cord for both mu- and kappa-opioids. Intraventricular application of mu-agonists produced maximal, dose-dependent antinociception. All kappa-agonists were also active in producing dose-dependent antinociception although curves were shallow and maximal antinociception could not be attained. The action of tifluadom was shown to be stereospecific. Naltrexone was 10-fold more potent in blocking morphine as compared to U50,488H whereas nor-binaltorphimine, a preferential kappa-antagonist, was 6-fold more potent against U50,488H than morphine. Indeed, whereas a dose of 0.2 mg/kg of naltrexone reversed mu-agonist actions, this dose was inactive against all kappa-agonists: the actions of these could be antagonized only by 2.0 mg/kg. These data indicate that in addition to kappa-receptors in the spinal cord, kappa-receptors in the brain can mediate antinociception against noxious heat and pressure.     

Renal prostaglandins and natriuretic action of oxytocin and vasopressin in rats

The relationship between natriuretic activity of neurohypophysial peptides and renal prostaglandins (PGs) was investigated in anesthetized rats under water diuresis and on kidney homogenates. Over the course of water diuresis, urinary sodium excretion increased steadily, reaching a 3.5-fold increase in 90 min, but there was no significant change in PGE2 and PGF2 alpha excretion. Inhibition of PG synthesis by naproxen sodium abolished the increase in sodium excretion. Oxytocin (OT) and vasopressin, in submaximal antidiuretic doses, produced marked natriuresis to 2139% and 345% of the control rate, respectively, without a concomitant increase in PG excretion. [Leu4]OT, which is devoid of antidiuretic activity, produced natriuresis and diuresis also without a significant effect on PG excretion. Inhibition of PG synthesis by naproxen attenuated the natriuretic response but enhanced the antidiuretic response to OT. Both the natriuretic and diuretic responses to [Leu4]OT were attenuated. Although the possibility that naproxen may have antinatriuretic activity independent of its PG synthesis inhibitory action cannot be excluded, the data obtained are consistent with our postulate that the natriuretic effect of OT-peptides may be mediated in part via a renal PG mechanism. This postulate is strengthened further by our findings that natriuretic peptides, OT, vasopressin and [Leu4]OT stimulated PG synthesis in kidney homogenates in a dose-dependent manner. Their order of potency is in the same order of their relative natriuretic potencies. [Penicillamine1,Phe(Methyl)2,Thr4,Orn8]OT, an OT antagonist and non-natriuretic, had no significant PG synthesis stimulating activity in the kidney homogenates.     

Renal action of a novel uricosuric diuretic, S-8666. I. Clearance and tubular microinjection studies in rats

Clearance and tubular microinjection techniques were used to evaluate the effects of a novel uricosuric diuretic, S-8666, on renal function and tubular absorption of urate by the rat kidney. Tubular sites of diuretic action of S-8666 were determined indirectly using osmolar clearance techniques. The i.v. injection of S-8666 at a dose ranging from 0.3 to 3.0 mg caused a dose-dependent increase in urine flow and sodium excretion. Potassium excretion was increased significantly but the increase was not marked as compared with sodium excretion. Glomerular filtration rate was not changed by S-8666. The diuretic response reached a maximum within 5 min and was retained for 45 min with 1 mg of S-8666. The comparison with the effect of furosemide revealed that furosemide was 13 times more potent than S-8666. Both the free water reabsorption on hydropenia and free water clearance in hydrated animals decreased with administration of S-8666. The urinary excretion of urate increased significantly after the administration of S-8666. By contrast, furosemide did not increase urinary excretion of urate. Total urinary urate recovery after S-8666 administration was higher after the microinjection of [14C]urate into early proximal tubule sites. We conclude that S-8666 acts as a uricosuric diuretic agent with the major site of altered urate absorption being in the proximal convoluted tubule and the major site of diuretic action being in the cortical and medullary diluting segments.     

Renal angiomyolipoma.

An unusual case of a patient with tuberous sclerosis who presented initially with renal symptoms is presented. Electromicroscopic observations showed the smooth muscles to contain myofilaments and an unusual amount of glycogen. Although the response of the tumor vessels to epinephrine in angiomyolipoma is considered similar to that of renal cell carcinoma in that no vasoconstriction occurs, the reverse occurred in our case. A thin, lucent cleavage line around portions of the periphery of the angiomyolipoma was also noticed. Isolated angiomyolipoma in patients without tuberous sclerosis is difficult to differentiate from renal cell carcinoma; therefore, radical nephrectomy is usually the treatment of choice. Angiomyolipomas associated with tuberous sclerosis are easier to diagnose and are multiple and bilateral; therefore, a more conservative approach usually is indicated.     

Renal transplantation.

This article provides an overview of the renal transplantation process from the evaluation phase through hospitalization and follow-up care. Nursing care of the postoperative transplant patient in the intensive care unit is detailed in this article, using nursing various diagnoses as a guideline.