Defining hypercalciuria in nephrolithiasis.

The classic definition of hypercalciuria, an upper normal limit of 200 mg/day, is based on a constant diet restricted in calcium, sodium, and animal protein; however, random diet data challenge this. Here our retrospective study determined the validity of the classic definition of hypercalciuria by comparing data from 39 publications analyzing urinary calcium excretion on a constant restricted diet and testing whether hypercalciuria could be defined when extraneous dietary influences were controlled. These papers encompassed 300 non-stone-forming patients, 208 patients with absorptive hypercalciuria type I (presumed due to high intestinal calcium absorption), and 234 stone formers without absorptive hypercalciuria; all evaluated on a constant restricted diet. In non-stone formers, the mean urinary calcium was well below 200 mg/day, and the mean for all patients was 127±46 mg/day with an upper limit of 219 mg/day. In absorptive hypercalciuria type I, the mean urinary calcium significantly exceeded 200 mg/day in all studies with a combined mean of 259±55 mg/day. Receiver operating characteristic curve analysis showed the optimal cutoff point for urinary calcium excretion was 172 mg/day on a restricted diet, a value that approximates the traditional limit of 200 mg/day. Thus, on a restricted diet, a clear demarcation was seen between urinary calcium excretion of kidney stone formers with absorptive hypercalciuria type I and normal individuals. When dietary variables are controlled, the classic definition of hypercalciuria of nephrolithiasis appears valid.

Indomethacin secretion in the isolated perfused proximal straight rabbit tubule. Evidence for two parallel transport mechanisms.

We studied indomethacin as a probe of anion transport across the isolated perfused proximal straight tubule of the rabbit and discovered that a substantial component of transport may occur by anion exchange at the basolateral membrane. Various perturbations involving direct or indirect dissipation of the cellular sodium gradient (ouabain, sodium- or potassium-free solutions, cooling to 18 degrees C) resulted in only a 50% inhibition of indomethacin transport, which raised the question of a co-existent alternative pathway for secretion. Similarly, the anion exchange inhibitor, 4,4'-diisothiocyanostilbene (DIDS), diminished indomethacin secretion by only 50%. Cooling followed by DIDS or the reverse sequence resulted in additive inhibition such that the combination abolished active secretion of indomethacin. We conclude that active secretion of indomethacin by the proximal straight tubule appears to be in part sodium gradient dependent; the remainder may be driven by an anion exchanger on the basolateral membrane.

Exaggerated natriuretic and calciuric responses to hydrochlorothiazide in renal hypercalciuria but not in absorptive hypercalciuria.

Patients with hypercalciuria have been reported to have an exaggerated response to hydrochlorothiazide (HCTZ), implying a renal tubular defect in solute reabsorption. To determine whether this disturbance is generalized or unique to a particular pathogenetic type of hypercalciuria, we measured the increments in urinary sodium (delta Na), calcium (delta Ca), and magnesium after a 100-mg dose of oral HCTZ in 10 normal subjects and 31 patients with different types of hypercalciuric nephrolithiasis. Eleven patients with renal hypercalciuria had significantly greater delta Na (P less than 0.005) and delta Ca (P less than 0.005) than the normal subjects. Ten patients with absorptive hypercalciuria and 10 patients with fasting hypercalciuria without parathyroid stimulation had delta Na and delta Ca indistinguishable from those of normal subjects. In all groups, urinary HCTZ and basal 24-h urinary Na did not differ. The results suggest that the unique natriuretic and calciuric responses to HCTZ occur only in renal hypercalciuric patients with secondary hyperparathyroidism. The data support a renal tubular defect in renal hypercalciuric in contrast to other diagnostic categories of hypercalciuric nephrolithiasis.

Effect of indomethacin on salt and water homeostasis.

The effects of indomethacin-induced prostaglandin inhibition on sodium and chloride homeostasis in normal man were assessed. Seven normal subjects were on a 150-mEq sodium diet for 3 days prior to receiving indomethacin or no drug. Indomethacin decreased fractional excretions of sodium and chloride without affecting fractional excretion of potassium, creatinine clearance, or percent fractional reabsorption of free water. Cumulative sodium excretion at 8 hr fell from 49.8 +/- 7.2 to 16.1 +/- 4.8 mEq (p less than 0.005) after indomethacin. Chloride fell at 8 hr from 49.7 +/- 6.4 to 21.3 +/- 5.1 mEq (p less than 0.005). Urinary volume and osmolal clearance decreased in similar magnitudes such that free water reabsorption was not changed by indomethacin. This study showed that indomethacin decreased renal sodium and chloride excretion, implying that endogenous prostaglandins may be modulators of renal sodium excretion.

Renal sites of action of azosemide.

Azosemide is a new monosulfamyl diuretic with potency and spectrum of effects similar to those of furosemide. Eight normal subjects were studied with clearance techniques during water loading and during hydropenia to assess azosemide's site of action. Solute free water reabsorption decreased from 3.1 +/- 0.3 to 0.5 +/- 0.9 ml/min after azosemide (p less than 0.05), indicating an effect of azosemide at the ascending limb of the loop of Henle. During water loading, despite significant 3.5-fold increases in fractional excretion of sodium and chloride, the per cent increase in free water formation, CH2O/CIN X 100 was not significantly changed by azosemide (10.4 +/- 1.4 control and 14.8 +/- 3.1 after azosemide). This unchanged CH2O/CIN X 100 occurred despite increased osmolal clearance after azosemide, from 2.6 +/- 0.4 to 3.8 +/- 0.4 ml/min (p less than 0.02), indicating that azosemide increased delivery of solute to the diluting segment. Evidence is discussed which implies that azosemide inhibits solute transport of the thick ascending limb of the loop of Henle, but may also affect more proximal sites.

Effects of probenecid on furosemide response.

Furosemide gains access to its intraluminal site of action by active secretion by the organic acid transport system of the proximal tubule. Inhibition of this transport by probenecid would predictably decrease the effect of furosemide. In this study in 8 normal volunteers, however, the opposite occurred; namely, pretreatment with probenecid increased the overall response to furosemide by prolonging its effect. Sodium excretion in 8 hr due to 40 mg of furosemide rose from 262 +/- 16 to 358 +/- 11 mEq after probenecid. Urine volume increased from 3,265 +/- 275 to 4,165 +/- 183 ml after probenecid. Analysis of the time-course of the increased diuresis and natriuresis showed that probenecid actually decreased the response for the first 60 to 90 min after furosemide but increased the subsequent response sufficiently to result in a greater overall effect. Possible explanations include access of furosemide to its active site from the serum, an effect of probenecid on prostaglandin transport, and a changing pharmacokinetic interaction between probenecid and furosemide.

Increase in diuretic effect of chlorothiazide by probenecid.

Thiazide diuretics reach their presumed intraluminal site of action by active transport at the organic acid secretory site of the proximal tubule. Probenecid competes for this transport and might therefore affect the diuresis induced by thiazide at that site. Doses of 500 mg and 1 gm of chlorothiazide (CTZ) intravenously to 5 volunteers with probenecid pretreatment increased 8-hr rates of excretion of sodium and urine over that without probenecid. Eight-hour excretion of sodium after administering 500 mg of CTZ was 147 +/- 7.5 mEq and 257.9 +/- 16.4 mEq after CTZ with probenecid (p less than 0.0005). The volume of urine after CTZ was 728 +/- 37 ml and 1,886 +/- 301 ml after CTZ with probenecid (p less than 0.001). This increase was associated with prolongation of CTZ diuresis rather than increase in intensity. These results are consistent with CTZ reaching its site of action from the peritubular side or that prolonged exposure of the lumen to lesser amounts of filtered CTZ causes a greater overall effect.

Sites of action of tripamide.

Tripamide is a new diuretic derived from a sulfonamide nucleus that has both antihypertensive and natriuretic properties. We assessed its renal site of effect with standard clearance techniques. Studies during water loading indicated a 47% increase in fractional free water clearance (an effect opposite that of thiazide diuretics) and a simultaneous 75% increase in fractional delivery of solute to the diluting segment. Consequently, when free water clearance was assessed relative to delivery of solute, tripamide induced a decrease from 0.86 +/- 0.03 to 0.75 +/- 0.01. This indicated an inhibitory effect on solute reabsorption at the cortical segment of the thick ascending limb of Henle's loop. Studies during hydropenia indicated increased free water reabsorption. When factored for delivery of solute, however, free water reabsorption decreased from 0.66 +/- 0.02 to 0.61 +/- 0.02, indicating a site of effect of tripamide at the medullary segment of the thick ascending limb of Henle's loop. Tripamide also increased calcium excretion. No effects on renal hemodynamics or indices of effect at the proximal tubule were observed. The data indicate that tripamide is a loop diuretic that may also affect more proximal nephron sites.

Digoxin toxicity in patients with normokalemic potassium depletion.

Reviews of large series of patients with digitalis-induced arrhythmias create a seeming paradox: Hypokalemia is infrequently associated with digitalis-induced arrhythmias but the clinical benefit of supplementation of potassium for most digitalis-induced arrhythmias is obvious. Examination of the electrophysiologic abnormalities induced by digitalis coupled with the electrophysiologic effects dependent on the ratio intracellular to extracellular concentrations of potassium clarifies the issue. We present evidence that supports additive effects of the toxicity of digitalis and abnormal ratios of concentrations of potassium inside and outside the cardiac cell. We provide guidelines for assessing this crucial ratio of intracellular to extracellular concentrations of potassium to aid the clinician in the diagnosis and effective treatment of digitalis-induced arrhythmias.

Clinical pharmacology of torasemide, a new loop diuretic.

Torasemide is a new loop diuretic that potentially may have renal tubular effects from both the blood and urinary sides of the nephron. We assessed its pharmacokinetics and pharmacodynamics in eight normal subjects administering intravenous doses of 5, 10, and 20 mg compared with 40 mg furosemide. We assessed the effect of probenecid on response to the 20 mg dose. A dose intermediate to the 10 and 20 mg doses appeared equally natriuretic to 40 mg furosemide. Although total clearance was the same with all doses (about 0.45 ml/min/kg), renal clearance and the fraction of unchanged drug appearing in the urine decreased with higher doses raising the question of saturable renal secretion. Urinary dose-response curves showed torasemide to be five times as potent as furosemide. Probenecid pretreatment decreased both urine volume (P = 0.0016) and sodium excretion (P = 0.0003), implying that delivery of drug to the urinary side of the nephron is the major determinant of response.

Furosemide in patients with heart failure: shift in dose-response curves.

We studied 10 patients with congestive heart failure to assess the dynamics of their response to 40 mg of furosemide. Patients excreted less sodium than normal controls: 142 +/- 36 and 245 +/- 16 mEq/4 hr (p < 0.05). Patients delivered the same amount of furosemide into the urine--14.9 +/- 2.0 and 18.7 +/- 2.1 mg/4 hr (p < 0.20)--but the time course of delivery differed. Normal subjects had a sigmoid-shaped curve when furosemide excretion rate was related to response. All patients but one had shifts in this curve and for a number of patients the configuration differed substantially from a sigmoid curve.

Azosemide, a "loop" diuretic, and furosemide.

Azosemide is a new monosulfamyl diuretic which inhibits solute transport throughout the thick ascending limb of the loop of Henle. This study compared equal amounts of azosemide and furosemide (20, 40, and 80 mg) in normal subjects. No differences occurred at any dose in volume, sodium, or chloride excretion when analyzed as cumulative excretion at 4, 8, or 12 hr. Azosemide 40 mg caused less potassium excretion than 40 mg of furosemide but there was no significant difference in the sodium/potassium excretion ratio. Analysis of the time course of effect showed that compared to furosemide azosemide tended to have a slower onset of effect. Differences in site of action studies between azosemide and furosemide did not manifest as differences in urinary or electrolyte excretion in our normal subjects.

Response to furosemide in chronic renal insufficiency: rationale for limited doses.

Patients with renal insufficiency often undergo therapy with large doses of loop diuretics. We tested the hypotheses that remaining nephrons respond normally to amounts of diuretic reaching them, and that more limited doses than are commonly used are sufficient to reach effective portions of the dose-response curve. In eight patients with creatinine clearance less than 20 ml/min/1.73 m2, the amount of diuretic causing half-maximal response was identical to that in normal subjects, but the maximal response expressed as fractional excretion of sodium was increased approximately 60%. The upper plateau of the dose-response curve was attained with single intravenous doses of furosemide, 120 to 160 mg. In conclusion, remnant nephrons appear to demonstrate an exaggerated response to furosemide. Because maximal response was attained with single intravenous doses of furosemide of 120 to 160 mg, there appears to be no need to administer larger single doses in such patients.

Effect of high-dose etodolac on renal function.

Previous studies from our laboratory have demonstrated transient effects on renal function by etodolac, 200 mg b.i.d. The current study assessed the effects of a larger dose of etodolac (500 mg b.i.d.) to explore the time course of its renal effects and to determine whether the transient effect would become more prolonged with a larger dose. We studied 10 normal subjects and nine patients with renal insufficiency, examining the effects of the first 500 mg dose of etodolac as well as 4 days of b.i.d. administration. In both groups, etodolac transiently decreased fractional excretions of sodium and chloride and urinary prostaglandin E2. In patients, etodolac also transiently decreased inulin and para-aminohippuric acid clearances and urinary 6-keto-prostaglandin F1 alpha. Chronic administration caused no changes in renal function in either group. In summary, in this relatively small group of patients, high-dose etodolac caused only transient, fully reversible effects on renal function, the cumulative effect of which was negligible.

Tiotidine and cimetidine--kinetics and dynamics.

Tiotidine and cimetidine kinetics and dynamics were compared to assess mechanisms of the longer duration of effect of tiotidine in man. Both drugs has similar lag times for absorption. Tiotidine with a meal was more slowly absorbed than when fasting and was also more slowly absorbed than cimetidine with a meal. The elimination rates for both drugs did not differ; they were both approximately 2 to 3 hr. Oral doses of cimetidine achieved areas under the plasma concentration curve approximately three times that of tiotidine but these concentrations were only 1/10 as potent. The cimetidine concentration inducing 50% inhibition of food-stimulated gastric acid secretion was 0.41 +/- 0.04 whereas it was 0.04 +/- 0.003 microgram/ml for tiotidine. The effect of tiotidine lasted longer than that of cimetidine because the doses recommended for use in man resulted in higher concentrations in plasma relative to effective concentration than clinical doses of cimetidine.

Azosemide kinetics and dynamics.

Azosemide is a loop diuretic that may also affect sodium reabsorption at the proximal tubule. We gave intravenous and oral doses of the drug to normal subjects to examine its kinetic and dynamic parameters. In the fasting state a lag time of absorption of approximately 1 hr was followed by absorption t 1/2s and elimination t 1/2s of approximately 0.75 and 2 2.5 hr. Only 2% of an oral dose was excreted unchanged in the urine. After intravenous dosing the elimination t 1/2 was approximately 2 hr; 20% of a dose was recovered unchanged. Thus azosemide has an estimated bioavailability of 10%. The relationship between urinary azosemide excretion rate ("dose") and natriuretic response follows a sigmoid-shaped curve with a dose inducing half-maximal response of 9.3 +/- 2.6 micrograms/min, whereas it is 69.8, 12.1 and 1 microgram/min for furosemide, piretanide, and bumetanide respectively.

Bumetanide and furosemide.

We assessed the response to and handling of furosemide and bumetanide in 30 experiments with the former and 46 with the latter in normal subjects. Oral doses of furosemide (20, 40, and 80 mg) were used, and subjects received oral doses of 0.5, 1, and 2 mg bumetanide and intravenous doses of 0.5 and 1 mg bumetanide. both drugs were quickly absorbed and peak urinary amounts were reached at 75 min (median). Approximately 30% of an oral dose of each drug was excreted unchanged in the urine with no evidence of dose-dependent elimination. After intravenous injection, 36% of the bumetanide was excreted unchanged. Consequently, bumetanide has an estimated bioavailability of 80% (approximately 40% for furosemide). The relationship between the logarithm of the urinary bumetanide excretion rate and the logarithm of the sodium excretion rate was described by a sigmoid-shaped dose-response curve, with a dose inducing half-maximal response of 1 +/- 0.04 micrograms/min; it was 69.8 micrograms/min for furosemide. Overall, the distinguishing features between the two drugs are the 200% greater bioavailability and the much greater potency of bumetanide.

Effects of piretanide in normal subjects.

Piretanide is a new loop diuretic similar to furosemide in pharmacologic properties and approximately six times as potent. We gave 3-, 6-, and 12-mg oral doses to 21 normal subjects and collected serial blood and urine samples for assessment of the drug's kinetics and dynamics. There was no evidence for dose-dependent elimination with the doses we used. Peak serum concentrations and urinary excretion rates appeared between 30 and 60 min. Elimination t1/2s were 60 to 90 min. Approximately 45% of a dose was recovered unchanged in the urine. Renal clearance rate was 90 to 100 ml/min and oral clearance was 200 ml/min. Examination of the relationship between urinary excretion rate of piretanide and sodium excretion allowed determination of potency at the tubular level. The piretanide dose that induced half-maximal response was 12.1 +/- 2.6 micrograms/min; it is 69.8 micrograms/min for furosemide and 1 micrograms/min for bumetanide. Piretanide kinetics, therefore, resemble those of furosemide and bumetanide, but piretanide is five or six times as potent as furosemide and one tenth as potent as bumetanide.

The interaction of diltiazem with simvastatin.

BACKGROUND: Simvastatin is an inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase that is used as a cholesterol-lowering agent and is metabolized by cytochrome P450 3A (CYP3A) enzymes. Diltiazem is a substrate and an inhibitor of CYP3A enzymes and is commonly coadministered with cholesterol-lowering agents such as simvastatin. The objective of this study was to quantify the effect of diltiazem on the pharmacokinetics of simvastatin. METHOD: A fixed-order study was conducted in 10 healthy volunteers with a 2-week washout period between the phases. In one arm of the study, a single 20-mg dose of simvastatin was administered orally; the second arm entailed administration of a single 20-mg dose of simvastatin orally after 2 weeks of treatment with 120 mg diltiazem twice a day. RESULTS: Diltiazem significantly increased the mean peak serum concentration of simvastatin by 3.6-fold (P < .05) and simvastatin acid by 3.7-fold (P < .05). Diltiazem also significantly increased the area under the serum concentration-time curve of simvastatin 5-fold (P < .05) and the elimination half-life 2.3-fold (P < .05). There was no change in the time to peak concentration for simvastatin and simvastatin acid. CONCLUSION: Diltiazem coadministration resulted in a significant interaction with simvastatin, probably by inhibiting CYP3A-mediated metabolism. Concomitant use of diltiazem or other potent inhibitors of CYP3A with simvastatin should be avoided, or close clinical monitoring should be used.

Pharmacokinetics of recombinant human superoxide dismutase in healthy volunteers.

We studied the pharmacokinetics and effects of recombinant human superoxide dismutase (rhSOD) in 32 normal human volunteers after intravenous bolus doses from 1 mg/kg to 45 mg/kg in a single-blind, placebo-controlled, crossover design. The drug was well tolerated. Neither cardiovascular nor renal function, such as the echocardiographically determined cardiac index, insulin or para-aminohippurate clearance, or the urinary excretion of beta 2-microglobulin or N-acetylglucosaminidase, was affected. Pharmacokinetic analysis by use of noncompartmental methods showed an overall half-life of rhSOD to be about 4 hours for doses from 3 mg/kg to 45 mg/kg. The peak concentrations ranged from 24 to 837 mg/L, and urinary excretion increased from 3% to 57% of total dose after single intravenous bolus administrations of the drug from 1 mg/kg to 45 mg/kg. The mean renal clearance of rhSOD initially increased with dose then plateaued at the highest dose, whereas the nonrenal clearance decreased with dose to a plateau; total clearance remained essentially constant. The progressive increase in renal clearance may be explained by saturation of the tubular reabsorption and degradation of the protein, a mechanism previously described in animal models.