Vasopressin Expressed in Hypothalamic CRF Neurons Causes Impaired Water Diuresis in Secondary Adrenal Insufficiency.

Patients with secondary adrenal insufficiency can present with impaired free water excretion and hyponatremia, which is due to the enhanced secretion of vasopressin (AVP) despite increased total body water. AVP is produced in magnocellular neurons in the paraventricular nucleus of the hypothalamus (PVH) and supraoptic nucleus and in parvocellular corticotropin-releasing factor (CRF) neurons in the PVH. This study aimed to elucidate whether magnocellular AVP neurons or parvocellular CRF neurons coexpressing AVP are responsible for the pathogenesis of hyponatremia in secondary adrenal insufficiency. The number of CRF neurons expressing copeptin, an AVP gene product, was significantly higher in adrenalectomized AVP-floxed mice (AVPfl/fl) than in sham-operated controls. Adrenalectomized AVPfl/fl mice supplemented with aldosterone showed impaired water diuresis under ad libitum access to water or after acute water loading. They became hyponatremic after acute water loading, and it was revealed under such conditions that aquaporin-2 (AQP2) protein levels were increased in the kidney. Furthermore, translocation of AQP2 to the apical membrane was markedly enhanced in renal collecting duct epithelial cells. Remarkably, all these abnormalities observed in the mouse model for secondary adrenal insufficiency were ameliorated in CRF-AVP-/- mice that lacked AVP in CRF neurons. Our study demonstrates that CRF neurons in the PVH are responsible for the pathogenesis of impaired water excretion in secondary adrenal insufficiency.

A snake toxin as a theranostic agent for the type 2 vasopressin receptor.

Rationale: MQ1, a snake toxin which targets with high nanomolar affinity and absolute selectivity for the type 2 vasopressin receptor (V2R), is a drug candidate for renal diseases and a molecular probe for imaging cells or organs expressing V2R. Methods: MQ1's pharmacological properties were characterized and applied to a rat model of hyponatremia. Its PK/PD parameters were determined as well as its therapeutic index. Fluorescently and radioactively labeled MQ1 were chemically synthesized and associated with moderate loss of affinity. MQ1's dynamic biodistribution was monitored by positron emission tomography. Confocal imaging was used to observe the labeling of three cancer cell lines. Results: The inverse agonist property of MQ1 very efficiently prevented dDAVP-induced hyponatremia in rats with low nanomolar/kg doses and with a very large therapeutic index. PK (plasma MQ1 concentrations) and PD (diuresis) exhibited a parallel biphasic decrease. The dynamic biodistribution showed that MQ1 targets the kidneys and then exhibits a blood and kidney biphasic decrease. Whatever the approach used, we found a T1/2α between 0.9 and 3.8 h and a T1/2ß between 25 and 46 h and demonstrated that the kidneys were able to retain MQ1. Finally, the presence of functional V2R expressed at the membrane of cancer cells was, for the first time, demonstrated with a specific fluorescent ligand. Conclusion: As the most selective V2 binder, MQ1 is a new promising drug for aquaresis-related diseases and a molecular probe to visualize in vitro and in vivo V2R expressed physiologically or under pathological conditions.

Syndrome of inappropriate antidiuretic hormone accompanied by bilateral hypothalamic and anterior thalamic lesions with serum antiaquaporin 4 antibody.

We described a rare case of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and severe unconsciousness accompanied by bilateral hypothalamic and anterior thalamic lesions with positive serum antiaquaporin 4 (AQP4) antibody. A 29-year-old man was admitted to our hospital due to the subacute progression of an unconscious state. He was observed to be hyponatraemic secondary to SIADH. Brain MRI showed bilateral hypothalamic and anterior thalamic lesions. Anti-AQP4 antibody was detected in his serum. After the administration of intravenous methylprednisolone pulse therapy, his symptoms improved with complete recovery from SIADH and regression of the hypothalamic and anterior thalamic lesions. The patient was transferred to another hospital for rehabilitation with 20 mg/day of oral prednisolone 127 days after admission. This case highlights the importance of testing for anti-AQP4 antibody in patients with unexplainable SIADH, subacute progressive unconsciousness and bilateral hypothalamic and anterior thalamic lesions.

Mineralocorticoid deficiency in post-operative cerebral salt wasting.

Acute hyponatremia, following neurosurgery, results from inappropriate antidiuretic hormone secretion (SIADH) or cerebral salt wasting (CSW). CSW is due to abnormally high atrial or brain natriuretic peptides (ANP, BNP), which block all stimulators of zona glomerulosa steroidogenesis, resulting in mineralocorticoid deficiency. A 3 year-old girl presented CSW at day 4, after resection of craniopharyngioma and hypophysectomy. Hyponatremia, hyperkalemia and high natriuresis occurred on day 8, with low renin and aldosterone and elevated BNP 120.3 ng/ml (undetectable before surgery). Fludrocortisone 100 microg/day controlled natriuresis and restored electrolytes within 24 hours. A 5 year-old boy presented CSW at day 6 after partial resection of optic glioma. Fludocortisone 100 microg/day restored electrolytes within 8 hours. ANP was elevated, 60.6 ng/l, aldosterone and renin were low. Fludrocortisone supplementation should be considered in CSW, as excessive natriuresis is controlled, and electrolytes are easily restored, avoiding life-threatening complications of this complex disorder.

Hyponatremia in patients with traumatic brain injury: incidence, mechanism, and response to sodium supplementation or retention therapy with hydrocortisone.

BACKGROUND: Hyponatremia is a frequently observed electrolyte abnormality in patients with central nervous system disease. Several mechanisms, such as SIADH, hypopituitarism, and CSWS, have been proposed with varied incidences among several studies. We attempted to clarify the incidence and mechanism of hyponatremia for each type of TBI. We also assessed the efficacy of sodium supplementation and retention therapy. For sodium retention therapy, hydrocortisone was administered, expecting its mineralocorticoid effect, when the hyponatremia was associated with excess natriuresis. METHODS: Retrospective analysis of 298 patients with TBI between January 2003 and December 2004 was performed. The incidence, background, clinical data, and outcome were evaluated. RESULTS: Of the 298 patients, 50 (16.8%) presented hyponatremia during the time course. Hyponatremia was associated with longer hospital stay (P < .001) and bad outcome (P = .02). Among these 50 patients, 37 recovered from the hyponatremia with simple sodium supplementation. The remaining 13 patients presented massive natriuresis and required additional sodium retention therapy. Hydrocortisone statistically reduced the amount of sodium excretion (P = .002) and returned the serum sodium level to a normal value. CONCLUSIONS: A high rate of hyponatremia after TBI was observed. Further studies are required to establish the precise mechanism of hyponatremia after TBI. Clear definition of CSWS is required to avoid confusion of the pathophysiology that causes hyponatremia. Hydrocortisone was useful to prevent excess natriuresis.

Vaptans and the treatment of water-retaining disorders.

Hyponatremia is a frequent and symptomatic electrolyte disorder for which specific treatments have been lacking. Hyponatremia is attributable to nonosmotic vasopressin stimulation and continued increased fluid intake. In the past, peptidic derivatives of arginine vasopressin proved that blockade of vasopressin V-2 receptors served to improve hyponatremia, however, these antagonists had intrinsic agonistic activity, too. In the past decade, random screening of molecules uncovered nonpeptide, orally available vasopressin antagonists without agonistic properties. The agents show competitive binding to the vasopressin V-2 receptor at an affinity comparable with that of arginine vasopressin. Four antagonists have undergone extensive study. Three of these agents--lixivaptan or VPA 985; SR 121 463 B; tolvaptan or OPC 41,061--are specific V-2 antagonists whereas conivaptan or YM 087 is a V-1/V-2 mixed antagonist. In animal and clinical studies all of the agents were able to correct water retention and hyponatremia in a dose-dependent manner. There was no tachyphylaxis, even when the agents were given over many weeks. It is expected that the clinical use of the agents will lead to a major improvement in the treatment of hyponatremia.

Hypertension in a patient with Gitelman's syndrome.

Gitelman's syndrome is an autosomal recessive disorder characterized by sodium wasting and hypotension. A middle-aged woman was diagnosed with Gitelman's syndrome because of typical clinical manifestations in the youth and homozygous mutations of 18-base-pair insertion in exon 6 of thiazide-sensitive NaCl-cotransporter gene. It was unusual that she showed hypertension with advancing age. Her serum potassium levels remained low at around 3.5 mEq/l despite potassium supplementation. This case demonstrates that hypertension could result in spite of the extremely decreased sodium reabsorption in Gitelman's syndrome and that essential hypertension is genetically heterogeneous, and abnormality of all genes may not be necessarily required to cause blood pressure rise.

Effect of sodium alterations on hepatic cytochrome P450 3A2 and 2C11 and renal function in rats.

Numerous dietary supplements are known to modulate cytochrome P450 (CYP)-mediated metabolism and subsequently alter drug toxicity or efficacy in animals and humans. In the present study we investigated the effect of varying amounts of sodium intake on renal function and the metabolic activity of the hepatic CYP3A2 and CYP2C11 isoforms. Rats were maintained on standard rodent chow or a low-salt rice diet. Within each of these groups rats received either a single intraperitoneal injection of furosemide to initiate salt depletion, or saline. Additional groups included salt supplementation of 500 mg/300 g body weight/day and 1.25 g/300 g body weight/day of sodium chloride solution. Rats receiving the low-salt diet, both with and without a concomitant furosemide administration, had a significant reduction in creatinine clearance without changes in serum creatinine. In addition, urine flow rate was markedly reduced in rats maintained on the low-salt diet. Western blot analysis indicated that neither sodium supplementation nor deprivation altered hepatic microsomal CYP3A2 levels; however, hepatic CYP2C11 levels significantly increased in rats receiving the largest sodium supplement. In vitro metabolic activity of CYP3A2 was unchanged as compared with controls. Activity of CYP2C11 was significantly reduced in both rat groups receiving additional sodium supplements. Acute manipulation of daily sodium intake does alter renal function and specific hepatic CYP isoforms and should be considered when using these rat models.

A patient with sodium- and potassium-losing nephropathy.

A young man with salt-losing nephropathy had the unusual coexistence of hypokalemia caused by secondary hyperaldosteronism. When his NaCl intake was supplemented by 12 g/day (205 mmol), hyperaldosteronism was suppressed and so were his urinary K wasting, hypokalemia, and episodic falling, during an extended follow-up. His findings are compared and contrasted with those in other reported patients with renal salt wasting, and also those in patients with Gitelman and Bartter syndromes.

Oral salt supplementation during ultradistance exercise.

OBJECTIVE: The objective of this study was to determine whether sodium supplementation 1) influences changes in body weight, serum sodium [Na], and plasma volume (PV), and 2) prevents hyponatremia in Ironman triathletes. SETTING: The study was carried out at the South African Ironman triathlon. PARTICIPANTS: Thirty-eight athletes competing in the triathlon were given salt tablets to ingest during the race. Data collected from these athletes [salt intake group (SI)] were compared with data from athletes not given salt [no salt group (NS)]. INTERVENTIONS: Salt tablets were given to the SI group to provide approximately 700 mg/h of sodium. MAIN OUTCOME MEASUREMENTS: Serum sodium, hemoglobin, and hematocrit were measured at race registration and after the race. Weights were measured before and after the race. Members of SI were retrospectively matched to subjects in NS for 1) weight change and 2) pre-race [Na]. RESULTS: The SI group developed a 3.3-kg weight loss (p < 0.0001) and significantly increased their [Na] (delta[Na] 1.52 mmol/L; p = 0.005). When matched for weight change during the race, SI increased their [Na] compared with NS (mean 1.52 versus 0.04 mmol/L), but this did not reach statistical significance (p = 0.08). When matched for pre-race [Na], SI had a significantly smaller percent body weight loss than NS (-4.3% versus -5.1%; p = 0.04). There was no significant difference in the increase of [Na] in both groups (1.57 versus 0.84 mmol/L). PV increased equally in both groups. None of the subjects finished the race with [Na] < 135 mmol/L. CONCLUSIONS: Sodium ingestion was associated with a decrease in the extent of weight loss during the race. There was no evidence that sodium ingestion significantly influenced changes in [Na] or PV more than fluid replacement alone in the Ironman triathletes in this study. Sodium supplementation was not necessary to prevent the development of hyponatremia in these athletes who lost weight, indicating that they had only partially replaced their fluid and other losses during the Ironman triathlon.

Overexpression of vasopressin in the rat transgenic for the metallothionein-vasopressin fusion gene.

Arginine vasopressin (AVP) is a major antidiuretic hormone, the overproduction of which causes diluting hyponatremia in humans and is called the syndrome of inappropriate antidiuresis (SIAD). To study physiological changes resulting from AVP overproduction and to develop an animal model of hyponatremia, the human AVP gene was expressed under the control of the metallothionein promoter in transgenic (Tg) rats. Analyses of AVP immunoreactivity (irAVP) in the tissues revealed that the transgene is expressed mainly in the central nervous system. Gel filtration showed that irAVP in the brain and plasma was properly processed AVP. AVP purified from the brains of both Tg and control rats also exerted equal bioactivity to generate cAMP in LLC-PK1 cells. The founder rats did not show any physical or anatomical abnormalities. Under basal conditions, Tg rats had high plasma AVP levels (Tg 13.8 +/- 2.5 pg/ml; control 2.7 +/- 1.2 pg/ml; n=6 in both groups; means +/- S.E.M.), decreased urine volume, and normal plasma [Na(+)]. Hypertonic saline injected i.p. did not affect AVP secretion in Tg rats. In response to a zinc-supplemented liquid diet, plasma AVP decreased in control rats, but increased in Tg rats (Tg 32.7 +/- 2.7 pg/ml; control 1.0+/-0.1 pg/ml; n=6), resulting in hyponatremia (Tg 135.2 +/- 2.5 mEq/l; control 140.8 +/- 0.4 mEq/l; n=6). To our knowledge, this is the first transgenic animal to show diluting hyponatremia. This transgenic rat may therefore provide a useful model in which to investigate various physiological alterations resulting from the oversecretion of AVP which involve SIAD, stress response, behavior, and blood pressure.

Natriuresis and "dilutional" hyponatremia after infusion of glycine 1.5%.

STUDY OBJECTIVE: To challenge the view that the hyponatremia resulting from absorption of glycine 1.5% is attributed to the expansion of the extracellular fluid (ECF) volume, and that the change in serum sodium is therefore widely used to calculate the amount of irrigant absorbed. DESIGN: Retrospective analysis of six studies. SETTING: University-affiliated hospital. MEASUREMENTS: Approximately 1.2 L of glycine 1.5% was infused in 23 volunteers (two studies), 1 L in 10 prostatectomy patients, 2.4 L in 6 sheep, 4 L in 6 other sheep, and 3 L in 9 piglets. The distribution of the irrigant water was estimated from the difference between the measured and the expected serum sodium levels, taking into account the urinary losses of sodium and water. MAIN RESULTS: Between 30% and 50% of the irrigant volume had diffused into the cells 30 minutes after the infusion, and only between 0% and 50% of the fluid remained in the ECF. One hour later, natriuresis accounted for 100% of the residual hyponatremia in the small-volume experiments, and it accounted for approximately 50% in the large-volume experiments. The change in serum sodium could not be used to quantify the small infusion volumes, but the large ones could be quantified fairly accurately if assessed at the very end of the infusion. CONCLUSIONS: Diffusion of water into the cells and natriuresis reduced and prolonged the hyponatremia associated with infusions of glycine 1.5%. This finding makes IV fluid with sodium added a more rational alternative than furosemide in the treatment of fluid overload with this irrigating solution.

Hyponatremia in the rat in the absence of positive water balance.

The purpose of this report is to determine the mechanisms that lead to hyponatremia when isotonic saline was the only fluid infused into rats given antidiuretic hormone (ADH), and what might minimize the degree of this hyponatremia. Normal rats were deprived of food and water for the 24-hr study period. They received an infusion of isotonic saline to expand their extracellular fluid (ECF) volume with and without exogenous ADH administration (N = 8 in each of the four groups). Similar studies were also carried out in 32 rats fed a low electrolyte diet for 72 hr before the experiment. An additional control group was fed the low electrolyte diet supplemented with sodium (Na), potassium (K), and chloride (Cl). Hyponatremia developed over 24 hr in rats fed their usual diet if treated with ADH and isotonic saline (fall, 13 +/- 2 mM, P < 0.01). The hyponatremia was caused by negative balance for Na + K salts. Hyponatremia did not develop after the saline + ADH treatment if rats were pretreated for 3 days with a low electrolyte diet. Two factors were required to develop this hyponatremia--generation of electrolyte-free water as a result of the excretion of a large quantity of Na + K salts at a high concentration in the urine, and prevention of the excretion of this electrolyte-free water by ADH. Increasing the avidity for Na reabsorption by the kidney prevented this type of hyponatremia from developing.

Testosterone and hypothalamic vasopressin expression in the hyponatremic rat.

The level of serum osmolality is known to influence the expression of the arginine vasopressin (AVP) gene in the rat hypothalamus. Accumulation of AVP messenger ribonucleic acid (mRNA) is enhanced by sustained hypernatremia and diminished by sustained hyponatremia. We recently reported that gonadal steroid hormones modify the accumulation of hypothalamic AVP mRNA during sustained hypernatremia (12). Gonadectomized (gdx) hypernatremic male rats failed to increase AVP mRNA abundance, and testosterone (T) restored the response. Therefore, we questioned whether the decreased accumulation of AVP mRNA in experimentally-induced hyponatremic male rats is influenced, in part, by circulating concentrations of T, and determined if AVP mRNA accumulation would differ in the hypothalamus of gdx vs intact hyponatremic animals. Decreased accumulation of AVP mRNA was found in both intact and gdx hyponatremic animals compared to normonatremic animals. The level of AVP mRNA accumulation was not correlated with serum T concentrations. We conclude that diminished AVP in the hypothalamus of hyponatremic male rats occurs independent of circulating T concentrations.

Effect of acute and chronic hyponatremia on brain buffering in rats.

The present studies evaluated whether previously observed impairments in brain buffering during acute hyponatremia were maintained during chronic hyponatremia as well and whether the impairment was due in part to changes in brain water, brain perfusion, or activation of arginine vasopressin (AVP) V1 receptors. Acute (1 and 2 day) and chronic (7 and 14 day) hyponatremia was induced in male Sprague-Dawley rats by constant desmopressin administration in combination with a liquid diet. Brain pH was determined by 31P nuclear magnetic resonance (NMR) in rats anesthetized with N2O and paralyzed with pancuronium. Brain buffering was evaluated by the response to CO2 loading, and brain perfusion was evaluated by 19F-NMR using trifluoromethane washout. Compared with normonatremic controls fed the same diet, brain pH in both acute and chronic hyponatremics was 0.12 pH units lower after 55 min ventilation with 20% CO2 despite identical decreases of approximately 0.35 units in all groups during the first 15 min. Moreover, in the recovery period brain pH overshot basal levels only in normonatremic controls. Brain water content in chronic hyponatremic rats was equal to controls, and brain perfusion was identical in the five groups during CO2 exposure. These results are analogous to those reported during acute hyponatremia induced with AVP and show that the impairment of active brain buffering is maintained during chronic hyponatremia and is unrelated to brain water content, perfusion, tissue catabolism, or AVP V1 receptor activation.

Effect of acute and chronic hyponatremia on blood-brain barrier function in the rat.

To study whether acute or chronic hyponatremia alters blood-brain barrier (BBB) permeability, rats made hyponatremic by constant desmopressin acetate infusion were studied by NMR spectroscopy and imaging. On constant volume ventilation and nitrous oxide, acute (1- and 2-day) and chronic (7- and 14-day) hyponatremic and normonatremic controls were infused with 0.25 M HCl. Despite reducing blood pH by at least 0.35 in < 50 min, brain pH, measured by 31P NMR, was unaffected in any group. As a second test of BBB function, gadolinium-DTPA (Gd-DTPA) was injected intravenously in these five groups. Coronal slice 1H NMR images obtained before and after Gd-DTPA showed image intensity changes in multiple areas outside brain, but neither control nor hyponatremic rats showed any differences in cortex, white matter or cerebellum. To ascertain whether the threshold for BBB disruption was altered, hypertonic mannitol (1.5, 2.0 or 3.0 mL) was injected rapidly into one internal carotid artery and pre- and post-Gd-DTPA images obtained. In both control and hyponatremic rats only the largest dose caused detectable Gd-DTPA leakage into brain. Thus, BBB function appears intact in both acute and chronic hyponatremia since neither H+ nor GD-DTPA penetrated the barrier and resistance to mannitol disruption was unaffected by hyponatremia.

Vasopressin transport regulation is coupled to the synthesis rate.

Vasopressin is synthesized in the perikarya of magnocellular neurons and is transported down long axons to the storage terminals of the posterior pituitary. To maintain stable pituitary stores following vasopressin secretion, the hypothalamus must synthesize and transport an amount of new vasopressin, equivalent to the amount released. Vasopressin release and synthesis rate can be chronically upregulated or suppressed relative to basal levels, depending on the demand for vasopressin. We studied whether vasopressin transport was similarly regulated during situations of varying demand. During chronic hyponatremia, when synthesis of vasopressin was reduced to undetectable levels, transport of vasopressin was also markedly decreased, as evidenced by continued presence of vasopressin in the transport system. Upregulation of transport was demonstrated by measuring pituitary accumulation of vasopressin in rats whose pituitary stores were initially depleted by hypernatremia and in whom subsequent release was suppressed by hyponatremia. In hypernatremic rats, transport of vasopressin was increased fivefold over baseline as determined by pituitary accumulation, and this elevated rate persisted for 7 days in the absence of release. This study demonstrates that axonal transport of vasopressin is a regulated process and is linked to synthesis rate rather than release.

[Evaluation of the changes in intracranial water, sodium, phosphorus metabolites and intracellular cerebral pH in rats with acute dilutional hyponatremia].

Although most prominent among the clinical manifestations associated with hyponatremia are central nervous system (CNS) symptoms, the alterations in brain function remain poorly understood. In the present study, the alterations in intracellular cerebral pH and intracranial water, sodium and phosphorus metabolites content in rats with acute dilutional hyponatremia were examined by using an in vivo nuclear magnetic resonance (NMR) technique which noninvasively provides continuous informations on intracellular phenomena. Acute dilutional hyponatremia was induced on anesthetized male Sprague-Dawley rats by intraperitoneal injection of distilled water with an initial dose of 10 ml/100 g bw, followed by an additional dose of 5 ml/100 g bw 40 min later. Arterial blood sampling and NMR measurements were made before and every 60 min after the initial injection of distilled water. The treatment with distilled water resulted in dramatic falls in serum Na, Cl and osmolality at 60 min after water loading (Na; from 143.4 +/- 2.6 to 112.3 +/- 1.3 mmol/l, Cl; from 101.02 +/- 2.2 to 78.4 +/- 5.4 mmol/l, Osm; from 306.3 +/- 5.8 to 247.3 +/- 7.3 mOsm/kg H20). 1H-NMR imaging showed the accumulation of brain water as dilutional hyponatremia developed. Intracranial Na content measured by 23Na-NMR spectroscopy decreased significantly at 60 min after of water loading to about 70% of that observed under control condition. Since it has been demonstrated that solute extrusion from the brain with resultant reduction of brain swelling occurs within 60 min after the dilution, this result may be, at least in part, explained by this protective mechanism.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of the measurement of uric acid fractional clearance in diuretic induced hyponatraemia.

The biochemical features of severe hyponatraemia due to thiazide administration in 7 non-oedematous patients were compared with those in hyponatraemia due to frusemide. Hypouricaemia has been shown to occur in hyponatraemia due to the syndrome of inappropriate antidiuretic hormone activity and this was measured along with fractional uric acid clearances in all the patients. Five of the patients had been on thiazides (or hydrochlorothiazide with amiloride) for only a few days to a few weeks. Fractional uric acid clearance was elevated and serum uric acid levels were low in five of them and returned to the normal range on restoration of serum sodium to normal. By contrast, the patients on frusemide did not show any abnormality in fractional uric acid clearance at any stage. These results are consistent with excess ADH activity as having caused hyponatraemia induced by thiazides in 5 of the 7 cases, whereas frusemide caused a sodium depletion syndrome. Treatment in the former cases is by water restriction, and in frusemide-induced salt depletion by saline supplementation.