Intrauterine growth retardation leads to a permanent nephron deficit in the rat

Intrauterine growth retardation (IUGR) was induced in Sprague-Dawley rats by partial artery ligation of one uterine horn in the mother on day 17 of gestation or by feeding the mother a 5% protein diet from day 8 of gestation. The controls were pups of the contralateral uterine horn or pups born to mothers fed a normal (22%) protein diet. The number of nephrons present at birth and the final number of nephrons in 2-week-old rats were counted throughout the entire kidney. The number of nephrons present at birth and the final number of nephrons were significantly correlated with birth weight for growth-retarded rats of both groups and their corresponding controls (P<0.02 for the poorest correlation). Clearance experiments and morphometric studies of 2-week-old rats born to mothers with uterine artery ligation indicated that, despite a large compensatory hypertrophy of the nephrons in those animals born with a nephron deficit of about 30%, the overal renal function was impaired. We conclude that IUGR is accompanied by a nephron deficit which may not be fully compensated for within the first weeks after birth.     

Nephron number and its determinants in early life: a primer

Although there is wide variation, humans possess on average 900,000 nephrons per kidney. So far as is known, nephrons cannot regenerate; therefore, an individual’s nephron endowment has profound implications in determining his or her long-term risk of developing chronic kidney disease. Most of the variability in human nephron number is determined early in life. Nephrogenesis is a complex and carefully orchestrated process that occurs during a narrow time window until 36 weeks gestation in humans, and disruption of any part of this sequence may lead to reduced nephron number. In utero, genetic abnormalities, toxic insults, and nutritional deficiencies can each alter final nephron number. Infants born prematurely must continue nephrogenesis in an ex utero environment where there may be multiple threats to successful nephrogenesis. Once the nephron endowment is determined, postnatal factors (such as acute kidney injury or chronic illnesses) can only decrease nephron number. Current techniques for estimating nephron number require an invasive procedure or complete destruction of the tissue, making noninvasive means for counting nephron surgently needed. A better understanding of nephron number and its determinants, particularly during growth and maturation, could allow the development of therapies to support, prolong, or resume nephrogenesis.     

Uncharted waters: nephrogenesis and renal regeneration in fish and mammals

The major functions of the vertebrate kidney are the removal of metabolic waste and the balance of salt and water. These roles are fulfilled by nephrons, which generally comprise a blood filter (glomerulus) attached to an epithelial tubule. The number of nephrons in the mammalian kidney is set at the end of kidney organogenesis in the late fetal or neonatal period. Subsequent increases in nephron size and functionality then occur during postnatal growth to match increases in body mass/fluid. Because of this strategy of renal development, injuries or birth defects that reduce nephron number lead to a permanent nephron deficit and increase the risk of kidney disease. In contrast to mammals, fish kidneys continue to add nephrons throughout their lifespan. In response to renal injury, fish increase the rate of nephrogenesis, effectively replacing lost nephrons and maintaining their nephron endowment. A better understanding of the remarkable nephrogenic abilities of fish kidneys may lead to innovative ways to restore nephrogenesis in the adult mammalian kidney. This review examines our current understanding of nephrogenesis in mammals and fish and explores possible explanations for why fish, but not mammals, utilize a perpetual nephrogenesis strategy to grow and maintain their kidneys.     

The number of nephrons in the mammalian kidney: environmental influences play a determining role

Several lines of evidence, mostly derived from animal studies, indicate that changes in the fetal environment may affect the renal development. Fetal growth retardation is associated with a nephron deficit in both humans and animals. Changes in the supply of vitamin A to the fetus may be responsible for the variations in the number of nephrons in the human kidney. In utero exposure to hyperglycemia or drugs may also cause a nephron deficit.     

Disparities in renal endowment: causes and consequences

In humans, nephrogenesis is completed by 36 weeks of gestation. Thus, human kidney development is complete at the time of birth in full-term infants. Those infants born before 36 weeks of gestation are still undergoing nephrogenesis for several weeks after their preterm birth and, accordingly, may be exposed to medications that impact the kidney during its final stages of renal development. The ultimate nephron number (nephron endowment) may influence future response to kidney injury, should it occur. The concept that nephron number may strongly influence blood pressure as well as susceptibility to kidney disease in later life developed in parallel with that of perinatal programming, which holds that the perinatal milieu causes changes that permanently alter organ structure and function, preordaining adult physiology to some extent. Both concepts together may help elucidate, at least in part, the pathogenesis of not only primary but secondary hypertension. This article summarizes human data on nephron number and its evaluation and considers the circumstances, implication, and management of persons born with or acquiring a decreased complement of nephrons early in life. Insufficient data exist to predict outcome or guide management. However, a common-sense approach of avoiding nephrotoxins and minimizing renal stress is indicated.     

Nephrotoxin exposure in utero reduces glomerular number in sclerosis-prone but not sclerosis-resistant mice

BACKGROUND: We have previously found that nephron number was not fixed, that is, there was a direct correlation between low birth weight and decreased nephron number in infants. In sclerosis-prone rats, we found that gentamicin exposure in utero induced a reduction in glomerular number and aggravated glomerulosclerosis in adults. In mice, we found that an inborn 50% reduction in nephron number, caused by the Os mutation, was associated with glomerulosclerosis in sclerosis-prone (ROP+/+) mice, but not in sclerosis-resistant (C57BL/6J) mice. Because the genetic background determined the response to decreased nephron number, we asked whether the susceptibility changes in glomerular number and glomerulosclerosis were linked. METHODS: Gentamicin was administered before and after the onset of fetal nephrogenesis. (1) Prior to the onset of nephrogenesis, two groups of pregnant mice were treated from embryonic day (E) E8 to E12. In group A, early glomerular development was studied by placing ureteric ridges removed on E12 in vitro for four days, following which the ureteric bud branches and glomeruli were counted using lectin staining. In group B, nephron number was determined in spontaneously delivered 14-day-old (14PN) pups by counting glomeruli. (2) After the onset of nephrogenesis, to determine the direct effects of gentamicin on nephron induction, ureteric ridges were placed in organ culture at E12 of normal gestation, in the presence or absence of gentamicin. The number of glomeruli and ureteric bud branches were counted after six days in culture. RESULTS: A decrease in glomerular number and ureteric bud branches was observed in sclerosis-prone (ROP+/+) mice, irrespective of whether gentamicin was administered prior to or after the onset of nephrogenesis. Glomerular number and ureteric bud branching were not decreased by gentamicin in sclerosis-resistant (C57BL/6) mice. CONCLUSIONS: These data provide evidence that there is a positive correlation between the susceptibility to glomerulosclerosis in adulthood and a reduction in nephron number in utero. Thus, exposure to nephrotoxins in utero compounds the risk of renal failure as an adult in sclerosis-prone individuals.     

In utero and in vitro exposure to beta-lactams impair kidney development in the rat

beta-Lactam antibiotics are widely used because of their lack of toxicity in humans. However, during pregnancy, exposure of the fetus is likely to occur because beta-lactam antibiotics cross the placenta. The potential adverse effects of two penicillins (ampicillin, amoxicillin) and of one cephalosporin (ceftriaxone) were examined in rat kidney development. Two experimental approaches were used: metanephros organ cultures to analyze the direct effect of the drug and maternal treatment to assess the consequences of in utero exposure. For in vitro experiments, metanephroi were removed from 14-d-old fetuses and grown with or without the antibiotic at a concentration ranging from 10 to 1000 microg/ml for 6 d. For in vivo experiments, pregnant rats were treated with penicillin at 100 mg/kg per d for 5 d, a period overlapping early renal organogenesis. Both penicillins alter renal development in vitro in a dose-dependent manner, from a dose of 10 microg/ml for ampicillin and 100 microg/ml for amoxicillin. In young animals exposed to penicillins in utero, a mild oligonephronia was present and cystic tubule dilation was observed in newborn and in young animals as well. Ceftriaxone weakly impairs in vitro nephrogenesis except at the dose of 1000 microg/ml that blocks kidney development completely. No effect on nephron ontogeny was observed following in utero exposure, but an interstitial inflammation was present in the medulla of 2-wk-old rats. In conclusion, these data show that beta-lactams, at therapeutic doses, are harmful to fetal rat kidneys.     

Compensatory renal growth after unilateral nephrectomy in the ovine fetus.

Unilateral nephrectomy of the adult animal results in compensatory renal growth but does not involve formation of new nephrons. It is not clear whether compensatory growth can occur during the period of active nephrogenesis in utero and if so, whether more nephrons can be formed. Male ovine fetuses (n = 20) underwent unilateral nephrectomy (n = 10) or sham nephrectomy (n = 10) at 100 d of gestation (term, 150 d). After 27 to 34 d, ewes and fetuses were killed and the right kidney of each fetus was removed and weighed. The wet weight of the right kidney was greater in the unilaterally nephrectomized fetuses (16.3 +/- 1.3 g compared with 12.2 +/- 0.7 g; mean +/- SEM, P < 0.05) as was the kidney to body weight ratio (5.2 +/- 0.3 g/kg compared with 3.8 +/- 0.2 g/kg; P < 0.001). Nephron number in the right kidney was estimated by an unbiased stereologic technique. There was a 45% increase in the number of nephrons in the kidneys from unilaterally nephrectomized animals compared with the kidneys from sham-operated animals (530,763 +/- 37,136 nephrons in the unilaterally nephrectomized group compared with 365,672 +/- 36,016 nephrons in the sham-operated group; P < 0.01). Mean glomerular volume was lower in the unilaterally nephrectomized group; however, total glomerular volume per kidney was not different between groups. This study demonstrates that there is a significant amount of compensatory growth and nephron endowment in a remaining kidney after unilateral nephrectomy during the period of active nephrogenesis in the sheep. This is the first time such events have been shown to occur in utero.     

Stereological assessment of renal development in a baboon model of preterm birth

At the time when most preterm babies are delivered, nephrogenesis is still ongoing, with the majority of nephrons normally formed during the third trimester of pregnancy. The extrauterine environment, however, is suboptimal for organogenesis, and therefore renal development is likely to be adversely affected by preterm birth. In the long-term, there is emerging evidence of high blood pressure and renal dysfunction amongst young adults born preterm. There is little knowledge to date, however, regarding the effects of preterm birth on renal structural development, perhaps due to the lack of an appropriate animal model. We have demonstrated that the baboon (Papio sp.) has a similar time course of nephrogenesis as the human kidney, and the baboon neonate can also be cared for in the same manner as a human neonate following preterm birth. Through a series of studies assessing renal development in the baboon model of preterm birth, involving the use of gold-standard stereological techniques, we have demonstrated that nephron endowment in the preterm baboon kidney is not reduced. Furthermore, antenatal glucocorticoid exposure prior to preterm delivery was associated with an increase in mature nephrons. There was, however, evidence of morphological abnormalities in a variable percentage of the glomeruli formed ex utero. Further research is therefore essential in order to establish what factors are involved in contributing to the glomerular abnormalities, and to identify ways in which 'normal' renal development can be conserved and optimised in the extrauterine setting.     

Adverse effects of hyperglycemia on kidney development in rats: in vivo and in vitro studies.

Congenital malformations occur more frequently in the offspring of diabetic mothers. These in vivo and in vitro studies investigate the potential adverse effects of hyperglycemia on kidney development in the rat. Female rats were made hyperglycemic throughout gestation with a single injection of streptozotocin (STZ) on day 0 of gestation, or for a short period encompassing the early stage of renal organogenesis by infusing glucose from gestational days 12-16. Kidney development in the pups was assessed by determining the total number of nephrons formed in the kidney. The number of nephrons was significantly reduced (10-35%) in the pups from STZ-treated dams, as a function of hyperglycemia. There were also fewer nephrons in pups from dams given glucose infusion whose hyperglycemia was transiently higher on day 13 of gestation. The in vitro experiments were done on metanephroi removed from 14-day-old fetuses and grown for 6 days in medium containing 0, 6.9, 13.8, or 27.5 mmol/l glucose. The development of explants grown in 0, 13.8, and 27.5 mmol/l glucose was impaired compared with that of explants grown in the 6.9 mmol/l control medium, showing that the glucose concentration must be closely controlled to ensure optimum in vitro metanephros development. Thus, exposure to hyperglycemia in utero can cause a nephron deficit, which in turn may have renal consequences later in life.     

Calcium signaling triggered by ouabain protects the embryonic kidney from adverse developmental programming

The kidney is extraordinarily sensitive to adverse fetal programming. Malnutrition, the most common form of developmental challenge, retards formation of the kidney’s functional units, the nephrons. The resulting low nephron endowment increases susceptibility to renal injury and disease. Using explanted rat embryonic kidneys, we found that the sodium-potassium-adenosine triphosphatase (Na, K-ATPase) ligand ouabain triggers, via the Na, K-ATPase/ inositol 1,4,5-trisphosphate receptor signalosome, a calcium-nuclear factor-kappa B (NF-κB) signal that protects kidney development from adverse effects of malnutrition. Serum deprivation resulted in severe retardation of nephron formation and robust increase in apoptotic rate, but in ouabain-exposed kidneys, no adverse effects of serum deprivation were observed. Depletion of intracellular calcium stores and inhibition of NF-κB activity abolished the rescuing effect of ouabain. Proof of principle that ouabain rescues development of embryonic kidneys exposed to malnutrition was obtained from studies on pregnant rats given low-protein diets and treated with ouabain or vehicle throughout pregnancy.     

Transplacental effects of gentamicin on endocytosis in rat renal proximal tubule cells

Changes in kidney maturation in utero have been reported after gentamicin administration to pregnant rats. While the proteinuria commonly observed, could be related to modifications of the glomerular basement membrane, perturbed renal protein handling could be accounted for by changes in the proximal tubular cells. Therefore, we studied the effect of gentamicin on the renal handling and transport of proteins in proximal tubular cells using the horseradish peroxidase, a fluid-phase marker, as a probe. Gentamicin was administered intraperitoneally to pregnant Wistar rats (75 mg/kg body weight per day) and neonatal kidneys were studied 1 day after birth. In proximal tubular cells of the deep cortical area, containing the fully matured nephrons of neonates, the transport and digestion of reabsorbed peroxidase was considerably reduced compared with controls where peroxidase reached lysosomes after endocytosis. Urinary protein excretion increased in treated animals. We conclude that gentamicin, entering the proximal tubular cells via the endocytic pathway, decreases the tubular reabsorption of proteins, thus increasing urinary protein excretion.     

Midkine is involved in kidney development and in its regulation by retinoids

In the kidney, in which development depends on epithelial-mesenchymal interactions, it has been shown that retinoids modulate nephrogenesis in a dose-dependent manner in vivo and in vitro. Midkine (MK) is a retinoic acid responsive gene for a heparin-binding growth factor. The aim of the present study was therefore to quantify the expression of MK mRNA during renal development in the rat, to analyze the regulation of MK expression by retinoids in vivo and in vitro, and, finally, to study the role of MK in rat metanephric organ cultures. The spatiotemporal expression of MK in fetal kidney was studied. In control rats, MK expression is ubiquitous at gestational day 14, i.e., at the onset of nephrogenesis. On day 16, MK is expressed in the condensed mesenchyme and in early epithelialized mesenchymal derivatives. On gestational day 21, MK is rather localized in the nonmature glomeruli of the renal cortex. In utero exposure to vitamin A deficiency did not modify the specific spatial and temporal expression pattern of MK gene in the metanephros, although a decrease in mRNA expression occurred. In metanephroi explanted from 14-d-old fetuses and cultured in a defined medium, expression of MK mRNA was found to be stimulated when retinoic acid (100 nM) was added in the culture medium. Finally, in vitro nephrogenesis was strongly inhibited in the presence of neutralizing antibodies for MK: the number of nephrons formed in vitro was reduced by approximately 50% without changes in ureteric bud branching morphogenesis. These results indicated that MK is implicated in the regulation of kidney development by retinoids. These results also suggested that MK plays an important role in the molecular cascade of the epithelial conversion of the metanephric blastema.     

Cortical and papillary absorptive defects in gentamicin nephrotoxicity

Renal function was examined in rats given daily injections of gentamicin (100 to 150 mg/kg) for 10 to 14 days. Whole kidney inulin clearance fell and urine volume increased. Single nephron GFR of surface nephrons varied. Some nephrons had no filtration, some had low rates, and some had high rates. Abnormal renal tubular epithelial inulin permeability was demonstrated by microinjection. Micropuncture of individual nephrons early and later in their course demonstrated reduced fluid reabsorption along the proximal convoluted tubule of superficial nephrons. Rates of fluid delivery to the late proximal and distal tubule were elevated. The rate of fluid reabsorption in the superficial loop of Henle was increased. Maximal urine osmolality and papillary tissue content of urea was reduced. The polyuria, therefore, results from decreased fluid reabsorption by proximal tubules and, probably, by papillary collecting ducts. The decrease in proximal fluid reabsorption is probably secondary to impaired solute reabsorption. A decrease in collecting duct fluid absorption can be attributed to the observed decrease in papillary solute concentration.     

Maternal diabetes modulates renal morphogenesis in offspring

Maternal diabetes leads to an adverse in utero environment, but whether maternal diabetes impairs nephrogenesis is unknown. Diabetes was induced with streptozotocin in pregnant Hoxb7-green fluorescence protein mice at embryonic day 13, and the offspring were examined at several time points after birth. Compared with offspring of nondiabetic controls, offspring of diabetic mice had lower body weight, body size, kidney weight, and nephron number. The observed renal dysmorphogenesis may be the result of increased apoptosis, because immunohistochemical analysis revealed significantly more apoptotic podocytes as well as increased active caspase-3 immunostaining in the renal tubules compared with control mice. Regarding potential mediators of these differences, offspring of diabetic mice had increased expression of intrarenal angiotensinogen and renin mRNA, upregulation of NF-kappaB isoforms p50 and p65, and activation of the NF-kappaB pathway. In conclusion, maternal diabetes impairs nephrogenesis, possibly via enhanced intrarenal activation of the renin-angiotensin system and NF-kappaB signaling.     

Retinoic acid enhances nephron endowment in rats exposed to maternal protein restriction

A reduced nephron complement at birth renders the kidney susceptible to renal disease in adulthood. Retinoic acid (RA; the active metabolite of vitamin A) is linked to nephrogenesis in vitro and in vivo. The aim of this study was to determine the effect of administration of retinoic acid in midgestation in rats on nephron endowment in offspring exposed to maternal protein restriction. Rats were fed either a normal-protein diet (NPD) or a low-protein diet (LPD) during pregnancy and lactation. Half of the dams in the LPD group were injected intraperitoneally with retinoic acid (20 mg/kg) during gestation at embryonic day 11.5. At 4 weeks of age, the offspring were anesthetized and perfusion-fixed, and nephron number estimated using unbiased stereological techniques. Body weight and kidney volume was significantly reduced in all LPD offspring. There was a significant 29% reduction in nephron number in the LPD group compared with the NPD offspring, whereas the number of nephrons in kidneys from the LPD + RA offspring was not significantly different compared with controls. In conclusion, administration of a single bolus dose of retinoic acid during midgestation restored nephron endowment to normal in offspring exposed to maternal protein restriction.     

Vesicoamniotic shunt for complete urinary tract obstruction is partially effective

Purpose

The long-term outcome for children after antenatal intervention for obstructive uropathies is disappointing. We reported that renal dysplastic changes are well established 3 weeks after obstruction in a fetal lamb model. We used this model to explore renal development and bladder function after fetal intervention.

Methods

We created an obstructive uropathy in fetal lambs at 60 days gestation by ligating the urethra and urachus. A vesicostomy (female) or urethrostomy (male) were performed 21 days later. The fetuses were killed at term (145 days) and bladder volume and compliance were measured. The urinary tract was processed for histologic examination.

Results

Twenty two fetuses were shunted. Nine were miscarried or were still-born. Thirteen survived, and 11 had a successful shunt with a small bladder (8 ± 5 mL) compared with controls (71 ± 19 mL) (P < .05). Shunted bladders had poor compliance. Histologically, they had thickened submucosal connective tissue with hypertrophied muscle. Histology of the renal tissue demonstrated relatively well-preserved renal architecture with reduced nephron mass (oligonephronia) in 2 lambs and multicystic dysplastic change in 3. Six (55%) had normal nephrogenesis.

Conclusions

In our model, shunt operations after obstructive uropathy fail to preserve bladder function. Shunting ameliorated the development of cystic dysplasia, but half of the lambs had oligonephronia or multicystic dysplastic kidney. These might develop renal failure later in life.     

Long-term effects of in utero exposure to cyclosporin A on renal function in the rabbit

The number of pregnant women who receive cyclosporin A (CsA) after transplantation or for autoimmune disease has increased. CsA and its metabolites can cross the placental barrier and thus interfere with fetal development. It was shown previously that rabbits that were exposed in utero to 10 mg/kg per d CsA from the 14th to the 18th day of gestation presented a 25% nephron reduction. Thus, this study was conducted to assess the long-term systemic and renal effects of a CsA-induced nephron reduction. Twenty-two pregnant New Zealand white rabbits were randomly divided into two groups: Twelve received 10 mg/kg per d CsA from day 14 to day 18 of gestation, and 10 were used as controls. Rabbits that were born to these animals were evaluated at 4, 11, 18, and 35 wk of life. Pups that were exposed antenatally to CsA presented first a permanent nephron deficit; second, glomerular, tubular, and intrarenal hemodynamics dysfunction; third, enlarged kidneys with numerous tubular and glomerular lesions; and, fourth, an endothelin-dependent systemic hypertension that worsened with age. In utero exposure to CsA induced a nephron reduction that led to systemic hypertension and progressive chronic renal insufficiency in adulthood. A long-term clinical survey is mandatory in infants who are born to mothers who were treated with cyclosporin during pregnancy.     

Renal function of children exposed to cyclosporin in utero.

BACKGROUND: The use of cyclosporin (CsA) has improved graft survival in transplant (Tx) patients despite its potential nephrotoxicity. Children born to transplanted women may present with intrauterine growth retardation (IUGR). On the basis of potential reduced nephron mass both in IUGR and in newborn experimental animals exposed to CsA in utero, we investigated the renal function of children >1 year of age born to women under maintenance immunosuppression, including CsA. METHODS: Fourteen children born to 12 Tx women (nine kidney, one pancreas-kidney, one heart, one liver) were investigated using inulin clearance (C(in)), para-aminohippuric acid clearance (C(PAH)), microalbuminuria, and electrolyte reabsorption rate. RESULTS: Gestational age of the 14 infants was 34+/-3 weeks and birth weight 2018+/-620 g. During pregnancy, CsA trough blood level was 234+/-115 microg/l and plasma creatinine range was 96-136 micromol/l. Two children were excluded from the study because renal investigation led to a diagnosis of hereditary nephritis (one Alport syndrome, one familial dominant focal segmental glomerulosclerosis) that was retrospectively completed in the mother. Renal function tests were finally performed in 12 children at 2.6+/-1.8 years of age: BP 94+/-7/55+/-5 mmHg, C(in) 117+/-28 ml/min/1.73 m(2), C(PAH) 545+/-124 ml/min/1.73 m(2), filtration fraction 0.23+/-0.03, microalbuminuria 4.2+/-3.5 mg/mmol. Electrolyte tubular reabsorption rates and urine concentrating capacity were normal. CONCLUSION: These results suggest that in children born to transplanted women taking CsA, renal function develops normally despite prolonged exposure in utero.