[Progressive renal failure caused by lithium nephropathy]. / Insuffisance rénale évolutive par néphropathie au lithium.

OBJECTIVES: Study the renal consequences of lithium therapy and find out whether lithium-induced chronic renal toxicity can provoke a progressive nephropathy, leading to advanced renal failure, requiring periodical dialysis. METHODS: Fifty-three patients treated with long-term lithium salts were included in the study. They had developed chronic renal failure (creatinine clearance inferior to 80 ml/min) not due to any other cause. RESULTS: These patients had received lithium salts for a mean period of 17.7 years. The mean reduction in creatinine clearance was of 2.23 ml/min/year. Final clearance correlated negatively with the duration of lithium administration. In 7 patients treated a mean of 22 years, progression towards terminal kidney failure required periodical dialysis. Around 30% of patients exhibited mild hypercalcemia. CONCLUSION: Lithium nephropathy inducing progressive renal failure is a reality. Its prevalence in patients treated long-term with lithium should be assessed.

Dramatic improvement of renal dysfunction in a human immunodeficiency virus-infected woman treated with highly active antiretroviral therapy.

We report a single case documenting substantial improvement in the course of human immunodeficiency virus (HIV)-associated, biopsy-proven nephropathy after introduction of highly active antiretroviral therapy. Our case report joins several others recording improvement or stabilization in the course of nephropathy following better control of HIV replication.

Screening of renal artery stenosis: assessment with magnetic resonance angiography at 1.0 T.

The results of MR angiography at 1.0 T with digital intraarterial angiography in the screening of patients with suspected renal hypertension were compared. In this first phase of the study, 10 volunteers underwent examination with both two-dimensional (2D) with traveling saturation time-of-flight (TOF) magnetic resonance angiography (MRA) with various parameters to develop a protocol for evaluation of the renal arteries. In the second phase, 36 patients with suspected renovascular hypertension underwent both 2D TOF MRA and intraarterial digital angiography to evaluate the clinical value of MRA. The degree of stenosis was graded with a two-point scale. In volunteers, using 2D acquisitions C/N ratios indicated the best flip angle as being 55 degrees (p = .02). MRA showed 100% (70/70) of all main arteries and 86% (6/7) of all accessory renal arteries seen on angiography. MRA had a sensitivity of 94% (15/16) and a specificity of 98% (60/61) for detection of stenoses of greater than 50% present in 14 patients. 2D-TOF MRA at 1.0 T shows promise in the noninvasive diagnosis of patients with suspected renovascular hypertension.

Characteristics and regulation of 11 beta-hydroxysteroid dehydrogenase of proximal and distal nephron.

Enzymatic properties of the enzyme 11 beta-hydroxysteroid dehydrogenase (11-HSD), which confers mineralocorticoid selectivity, have been explored in the aldosterone-sensitive collecting duct (CCD) and the aldosterone-insensitive Pars Recta (PR) of the rat kidney. After incubation of freshly isolated tubular segments with [3H]corticosterone (3H-B) or [3H]dehydrocorticosterone (3H-A), the rate of transformation of 3H-B into 3H-A (dehydrogenase activity), or the reverse reaction (reductase activity) were measured by HPLC, Vmax for dehydrogenase activity was found to be 8- to 10-fold higher in CCD than PR. The enzyme functions over a very wide range (0.1-5000 nM) of corticosterone concentration. In CCD, enzyme kinetics suggest either the presence of two 11-HSD forms, differing by their affinity for corticosterone, or complex kinetics. Addition of NAD or NADP to permeabilized tubules revealed that dehydrogenase activity is NAD-dependent in CCD and NADP-dependent in PR. Cofactor addition was ineffective in intact tubules. CCD exhibited an exclusive dehydrogenase activity, whereas in PR dehydrogenase and reductase activity were found. No regulation of dehydrogenase activity could be evidenced in adrenalectomized rats receiving or not aldosterone, corticosterone or dexamethasone, for 2 h, 3 days or 4 days. We conclude that 11-HSD in the CCD and PR differs by its Vmax and cofactor dependence. Corticosteroid hormones do not influence 11-HSD activity.

Human skin as target for aldosterone: coexpression of mineralocorticoid receptors and 11 beta-hydroxysteroid dehydrogenase.

The expression of mineralocorticoid receptors (MR) and 11 beta-hydroxysteroid dehydrogenase (11HSD) activity has been investigated in the epidermis and appendages of the human skin. Aldosterone binds to MR and regulates sodium transport in tight epithelia. Mineralocorticoid selectivity is achieved through coexpression of MR and 11HSD, which prevents permanent MR occupancy by glucocorticoids. Some forms of hypertension may involve abnormalities of MR and/or 11HSD. However, their direct assessment in humans remains difficult in the kidney or colon. This led us to explore this system in human skin easily accessible to biopsy. In situ hybridization with specific MR complementary ribonucleic acid probes and immunohistochemistry using three different anti-MR antibodies showed that MR was expressed at both the messenger ribonucleic acid and protein levels in the keratinocytes of the epidermis, in the sweat and sebaceous glands, and in the hair follicles. A significant 11HSD activity was found in isolated sweat gland ducts (5 fmol/3-mm length.10-min incubation with 10 nmol/L corticosterone as substrate) and was very low in the epidermis. In both structures, reductase activity was 10 times lower than that of dehydrogenase. Studies on the cofactor specificity of the enzyme showed a nicotinamide-adenine-dinucleotide preference in sweat glands, contrasting with a nicotinamide-adenine-dinucleotide phosphate dependence in epidermis. Human skin appears as a new target for aldosterone because it coexpresses MR and 11HSD. Our findings present the possibility to explore the functionality of the MR system in human tissue and its implications in various physiopathological situations.

The mineralocorticoid receptor discriminates aldosterone from glucocorticoids independently of the 11 beta-hydroxysteroid dehydrogenase.

To investigate the mechanisms involved in the in vivo aldosterone selectivity of the mineralocorticoid receptor (MR), we studied the respective contribution of the receptor and the enzyme 11 beta-hydroxysteroid dehydrogenase (11HSD), which converts glucocorticoids into inactive metabolites. Using a cotransfection assay in CV-1 cells, aldosterone activated mouse mammary tumor virus promoter through human MR (hMR) with an ED50 of 0.01 nM. An at least 100-fold higher concentration of cortisol (F), corticosterone (B), or dexamethasone was required to obtain half-maximum transactivation, indicating a functional preference of hMR for aldosterone over glucocorticoids. The catalytic activity of 11HSD was analyzed using HPLC by measuring the tritiated metabolites produced in CV-1 and COS cells. Both cell types displayed a significant dehydrogenase activity (20 fmol/10 min.10(3) cells) inhibitable by carbenoxolone, but no detectable reductase activity. In this model, B was more rapidly metabolized than F. Carbenoxolone treatment of hMR-transfected CV-1 cells did not result in a shift of the dose-response transactivation curves of B and F toward lower concentrations, ruling out the implication of 11HSD in the aldosterone MR selectivity of these conditions. Despite similar affinity constants of aldosterone and glucocorticoids for the hMR, kinetic experiments showed that the off-rate of aldosterone from hMR was 5 times lower than that of glucocorticoids, pointing to an intrinsic discriminating property of the receptor. Therefore, we propose that in addition to 11HSD, MR plays an active role in the mechanism of aldosterone selectivity.

Expression of 11 beta-OHSD along the nephron of mammals and humans.

The enzyme 11 beta-hydroxysteroid dehydrogenase (11 beta-OHSD) plays a major role in the protection of the mineralocorticoid receptor (MR). This cellular mechanism of aldosterone selectivity relies on the coexpression of MR and 11 beta-OHSD in the same cells. Localization of renal 11 beta-OHSD along the nephron is reviewed; comparison of data contained in different species is made; and original data is presented to show that the catalytic activity of the enzyme in tubules from human kidney is the highest in the mineralocorticoid-sensitive distal nephron.

Rat liver 11 beta-hydroxysteroid dehydrogenase complementary deoxyribonucleic acid encodes oxoreductase activity in a mineralocorticoid-responsive toad bladder cell line.

The mineralocorticoid receptor displays equal affinity for aldosterone and corticosterone. It has been proposed that aldosterone selectivity in vivo is achieved by the conversion of corticosterone into its inactive metabolite 11-dehydrocorticosterone by 11 beta-hydroxysteroid dehydrogenase (11 beta HSD). To test this hypothesis, we transfected rat liver 11 beta HSD cDNA into TBM cells, a sodium-transporting cell line. These cells respond equally well to aldosterone and corticosterone, indicating that endogenous 11 beta HSD is expressed at low levels in TBM cells. Although exogenous rat liver 11 beta HSD was expressed at high levels in transfected cells, mineralocorticoid selectivity was not observed. By contrast, the biologically inactive 11-dehydrocorticosterone was readily converted into corticosterone, a potent agonist for sodium transport. Our results indicate that rat liver 11 beta HSD behaves predominantly as a reductase in TBM cells. Another 11 beta HSD isoform is likely to be responsible for the dehydrogenase reaction in aldosterone-responsive cells.

Multiple patterns of 11 beta-hydroxysteroid dehydrogenase catalytic activity along the mammalian nephron.

The enzyme 11 beta-hydroxysteroid dehydrogenase (11 beta-OHSD) is thought to be a protective enzyme of the mineralocorticoid receptor (MR). We have previously demonstrated (Bonvalet et al, J Clin Invest 86:832-837, 1990) that 11 beta-OHSD is colocalized with MR along the rabbit nephron. In the present study, we examined whether 11 beta-OHSD is similarly located along the nephron of other mammals. Various tubular segments were microdissected from the mouse, rat, and rabbit nephron, and incubated for two hours at 37 degrees C in the presence of 11 nM [3H]-corticosterone (B). Thereafter, the respective amounts of B and [3H]-11dehydrocorticosterone (A) in the incubation solution were measured by HPLC. In the rabbit, the mouse and the rat, about 520 pmol/10 mm of B were transformed into A in tubular segments possessing MR, that is, the distal parts of the nephron (distal and collecting tubule). Differences appeared in the aldosterone-insensitive proximal tubule; in both the initial and final parts of this segment, 11 beta-OHSD activity was low (26 pmol/10 mm) in the rabbit and the mouse, and relatively high in the rat (328 pmol/10 mm). In the cortical part of the loop of Henle, where the presence of MR is still under discussion, 11 beta-OHSD activity was low in the mouse (70 pmol/10 mm), high in the rat (533 pmol/10 mm) and intermediate in the rabbit (227 pmol/10 mm). The comparison of these results with previous data obtained with immunohistochemical methods suggests that the proximal and distal nephron might express different isoforms of 11 beta-OHSD.

[A new regulatory mechanism of the action of corticosteroid hormones: cellular 11beta-hydroxycorticosteroid dehydrogenase]. / Un nouveau mécanisme de régulation de l'action des hormones corticostéroïdes: la 11 beta-hydroxycorticostéroïde déshydrogénase cellulaire.

Eleven-beta-hydroxysteroid dehydrogenase (11 beta OHSD) protects the aldosterone receptor (MR) against its occupancy by glucocorticoid hormones. We examined the intrarenal distribution of 11 beta OHSD, as compared to that of MR. MR were localized in histological sections from rabbit kidney, using immunohistochemical methods with an anti-MR monoclonal antibody. 11 beta OHSD activity was measured in isolated tubular segments from rabbit, rat and mouse kidneys. Tubules were incubated in the presence of tritiated corticosterone (3H-B:2 x 10(-8)M). Then the rate of degradation of 3H-B into 3H-11-dehydrocorticosterone (3H-A) was determined by HPLC. MR was immunodetected in the distal tubule and the collecting duct. No positive staining was present in the proximal tubule. The conversion rate of 3H-B into 3H-A was high (approximately 80%) in the distal and collecting tubule. It was low in the proximal tubule (less than 15%) except in the rat (approximately 50%). These results indicate that MR and 11OHSD are colocalized along the mammalian nephron. This colocalization constitutes a strong argument in favor of the MR-protective role of 11 beta OHSD, and of a role of a defect of this enzyme in the genesis of some types of arterial hypertension.

Mesangial IgA deposits in two patients with AIDS-related complex.

Two patients with AIDS-related complex who presented with renal failure and microscopic hematuria were found to have mesangial deposits of IgA at renal biopsy. Though such glomerular deposits have not yet been reported in patients with HIV infection, their occurrence is most likely not coincidental. Indeed, there are striking similar abnormalities in patients with primary IgA nephropathy and in those infected with HIV. A careful screening for microscopic hematuria may lead to disclose further cases of mesangial IgA deposits in patients with HIV infection.

[A new syndrome: acute interstitial nephropathy with uveitis. Apropos of a case]. / Un nouveau syndrome: les néphropathies interstitielles aiguës avec uvéite. A propos d'une observation.

A 17 year old female presented with an acute interstitial nephritis and anterior uveitis. She had constitutional symptoms, a biological inflammatory syndrome, circulating immune complexes and a negative tuberculin reaction. None of the usual causes of acute interstitial nephritis and/or uveitis was found; the infectious diseases work-up was negative and the diagnosis of Behcet's syndrome and sarcoidosis were excluded. The nephritis regressed spontaneously within a few weeks; the uveitis responded to local steroids. A review of the literature revealed 26 similar cases, which suggests that this syndrome is more than a coincidental association. The kidney and the eye could be target organs of humoral and cellular immune reactions to an acute antigenic aggression; the nature of this remains unclear.

Pyrazinamide and pyrazinoic acid pharmacokinetics in patients with chronic renal failure.

Pharmacokinetics of pyrazinamide and its major metabolite, pyrazinoic acid, were assessed in 10 chronic uremic patients treated by maintenance hemodialysis in comparison with 10 normal subjects. All subjects ingested a single dose of 1 g of pyrazinamide, the patients receiving the drug immediately after the end of a dialysis session. Bioavailability of pyrazinamide was only slightly increased in patients, its dialysis extraction coefficient being 55.3%. In contrast, pyrazinoic acid has an elimination rate-dependent metabolism with a bioavailability markedly increased in patients and a dialysis extraction coefficient of 59.8%. These data may lead to recommendations of a reduction in the dosage of pyrazinamide in dialysis patients. However, administering the usual dosage of the drug at the end of each dialysis session seems preferable to the daily administration of a reduced dosage.