[Development of a hyperkalemia risk assessment model for patients with chronic kidney disease].

Objective: To investigate risk factors for hyperkalemia among chronic kidney disease (CKD) patients and establish a risk assessment model for predicting hyperkalemia events. Methods: Clinical data of CKD patients (stage 3 to 5) hospitalized between May 2017 and June 2020 from 14 hospitals were retrospectively collected and divided into training dataset and validation dataset through balanced random sampling. Multivariate logistic regression analysis was used to analyze risk factors for hyperkalemia in CKD patients and the factors were scored. Receiver operating characteristic (ROC) curve was plotted and the area under the curve (AUC) was calculated. Meanwhile, the cut-off value with the best sensitivity and specificity were used to verify the accuracy of the model in validation dataset. Results: A total of 847 CKD patients were enrolled and further divided into training dataset (n=675) and validation dataset (n=172). There were 555 males and 292 females, with a mean age of (57.2±15.6) years. Multivariate logistic regression analysis showed that age, CKD stage, history of heart failure, history of serum potassium ≥5.0 mmol/L, diabetes, metabolic acidosis, and use of medications that increase serum potassium levels were risk factors for causing hyperkalemia in patients with CKD. Risk assessment model was established based on these risk factors. The AUC of the ROC curve was 0.809. Using 4 as the cut-off value, the sensitivity and specificity for predicting hyperkalemia events reached 87.1% and 57.0%, respectively. Conclusion: The model established in the current study can be used for predicting hyperkalemia events in clinical practices, which offers a new way to optimize serum potassium management in patients with CKD.

Physiologic and pathophysiologic roles of lipid mediators in the kidney.

Small lipids such as eicosanoids exert diverse and complex functions. In addition to their role in regulating normal kidney function, these lipids also play important roles in the pathogenesis of kidney diseases. Cyclooxygenase (COX)-derived prostanoids play important role in maintaining renal function, body fluid homeostasis, and blood pressure. Renal cortical COX2-derived prostanoids, particularly (PGI2) and PGE2 play critical roles in maintaining blood pressure and renal function in volume contracted states. Renal medullary COX2-derived prostanoids appear to have antihypertensive effect in individuals challenged with a high salt diet. 5-Lipoxygenase (LO)-derived leukotrienes are involved in inflammatory glomerular injury. LO product 12-hydroxyeicosatetraenoic acid (12-HETE) is associated with pathogenesis of hypertension, and may mediate angiotensin II and TGFbeta induced mesengial cell abnormality in diabetic nephropathy. P450 hydroxylase-derived 20-HETE is a potent vasoconstrictor and is involved in the pathogenesis of hypertension. P450 epoxygenase derived epoxyeicosatrienoic acids (EETs) have vasodilator and natriuretic effect. Blockade of EET formation is associated with salt-sensitive hypertension. Ceramide has also been demonstrated to be an important signaling molecule, which is involved in pathogenesis of acute kidney injury caused by ischemia/reperfusion, and toxic insults. Those pathways should provide fruitful targets for intervention in the pharmacologic treatment of renal disease.

Glycogen synthase kinase 3 inhibition improves insulin-stimulated glucose metabolism but not hypertension in high-fat-fed C57BL/6J mice.

AIMS/HYPOTHESIS: In the current study, the effect of a highly specific peptide inhibitor of glycogen synthase kinase 3 (GSK3) (L803-mts) on glucose metabolism and BP was examined in a high-fat (HF) fed mouse model of diabetes. METHODS: C57/BL6J mice were placed on an HF diet for 3 months and treated with L803-mts for 20 days, following which glucose metabolism was examined by euglycaemic-hyperinsulinaemic clamp studies. BP and heart rate were measured by radio-telemetry. RESULTS: The HF mice were obese, with impaired glucose tolerance and high plasma insulin and leptin levels. L803-mts treatment significantly reduced the insulin levels and doubled the glucose infusion rate required to maintain a euglycaemic condition in the HF+L803-mts group compared with the HF group. Insulin failed to suppress the endogenous glucose production rate in the HF group while decreasing it by 75% in the HF+L803-mts group, accompanied by increased liver glycogen synthase activity and net hepatic glycogen synthesis. GSK3 inhibition also reduced peripheral insulin resistance. Plasma glucose disappearance rate increased by 60% in the HF+L803-mts group compared with the HF group. In addition, glucose uptake in heart and gastrocnemius muscle was markedly improved. Although mean arterial pressure increased following the HF diet, it did not change significantly during the 12 days of L803-mts treatment. CONCLUSIONS/INTERPRETATION: These studies demonstrate that GSK3 inhibition improved hepatic and peripheral insulin resistance in a mouse model of HF-induced diabetes, but it failed to have an effect on BP. GSK3 may represent an important therapeutic target for insulin resistance.

Dehydration activates an NF-kappaB-driven, COX2-dependent survival mechanism in renal medullary interstitial cells.

Renal prostaglandin (PG) synthesis is mediated by cyclooxygenase-1 and -2 (COX1 and COX2). After dehydration, the maintenance of normal renal function becomes particularly dependent upon PG synthesis. The present studies were designed to examine the potential link between medullary COX1 and COX2 expression in hypertonic stress. In response to water deprivation, COX2, but not COX1, mRNA levels increase significantly in the renal medulla, specifically in renal medullary interstitial cells (RMICs). Water deprivation also increases renal NF-kappaB-driven reporter expression in transgenic mice. NF-kappaB activity and COX2 expression could be induced in cultured RMICs with hypertonic sodium chloride and mannitol, but not urea. RMIC COX2 expression was also induced by driving NF-kappaB activation with a constitutively active IkappaB kinase alpha (IKKalpha). Conversely, introduction of a dominant-negative IkappaB mutant reduced COX2 expression after hypertonicity or IKKalpha induction. RMICs failed to survive hypertonicity when COX2 was downregulated using a COX2-selective antisense or blocked with the selective nonsteroidal anti-inflammatory drug (NSAID) SC58236, reagents that did not affect cell survival in isotonic media. In rabbits treated with SC58236, water deprivation induced apoptosis of medullary interstitial cells in the renal papilla. These results demonstrate that water deprivation and hypertonicity activate NF-kappaB. The consequent increase in COX2 expression favors RMIC survival in hypertonic conditions. Inhibition of RMIC COX2 could contribute to NSAID-induced papillary injury.

Selective targeting of cyclooxygenase-2 reveals its role in renal medullary interstitial cell survival.

Renal medullary interstitial cells (MICs) are a major site of cyclooxygenase (COX)-mediated PG synthesis. These studies examined the role of COX in MIC survival. Immunoblot and nuclease protection demonstrate that cultured MICs constitutively express COX2, with little constitutive COX1 expression. SC-58236, a COX2-selective inhibitor, but not SC-58560, a COX1 inhibitor, preferentially blocks PGE2 synthesis in MICs. Transduction with a COX2 antisense adenovirus reduced MIC COX2 protein expression and also decreased PGE2 production. Antisense downregulation of COX2 was associated with MIC death, whereas a control adenovirus was without effect. Similarly, the COX2-selective inhibitor SC-58236 (30 microM) and several nonselective COX-inhibiting nonsteroidal anti-inflammatory drugs (NSAIDs), including sulindac, ibuprofen, and indomethacin, all caused MIC death. In contrast, SC-58560, a COX1-selective inhibitor, was 100-fold less potent for inducing MIC death than its structural congener SC-58236. NSAID-induced MIC death was associated with DNA laddering and nuclear fragmentation, consistent with apoptosis. These results suggest that COX2 plays an important role in MIC survival. COX2 inhibition may contribute to NSAID-associated injury of the renal medulla.

Type II cAMP-dependent protein kinase regulates electrogenic ion transport in rabbit collecting duct.

cAMP mediates many of the effects of vasopressin, prostaglandin E2, and beta-adrenergic agents upon salt and water transport in the renal collecting duct. The present studies examined the role of cAMP-dependent protein kinase (PKA) in mediating these effects. PKA is a heterotetramer comprised of two regulatory (R) subunits and two catalytic (C) subunits. The four PKA isoforms may be distinguished by their R subunits that have been designated RIalpha, RIbeta, RIIalpha, and RIIbeta. Three regulatory subunits, RIalpha, RIIalpha, and RIIbeta, were detected by immunoblot and ribonuclease protection in both primary cultures and fresh isolates of rabbit cortical collecting ducts (CCDs). Monolayers of cultured CCDs grown on semipermeable supports were mounted in an Ussing chamber, and combinations of cAMP analogs that selectively activate PKA type I vs. PKA type II were tested for their effect on electrogenic ion transport. Short-circuit current (Isc) was significantly increased by the PKA type II-selective analog pairs N6-monobutyryl-cAMP plus 8-(4-chlorophenylthio)-cAMP or N6-monobutyryl-cAMP plus 8-chloro-cAMP. In contrast the PKA type I-selective cAMP analog pair [N6-monobutyryl-cAMP plus 8-(6-aminohexyl)-amino-cAMP] had no effect on Isc. These results suggest PKA type II is the major isozyme regulating electrogenic ion transport in the rabbit collecting duct.

Regulation of renal function by prostaglandin E receptors.

Prostaglandin E2 is the major cyclooxygenase product of arachidonic acid metabolism produced along the nephron. This autacoid interacts with four distinct, G-protein-coupled E-prostanoid receptors designated EP1-EP4. The intrarenal distribution of each receptor has been mapped and the consequences of receptor activation examined. EP3 receptor mRNA is expressed highly in the medullary thick ascending limb (mTAL) and collecting duct (CD). EP3 receptor activation inhibits cAMP generation via Gi, thus inhibiting vasopressin-stimulated water reabsorption in the CD. EP3 receptor activation also may contribute to PGE2-mediated inhibition of NaCl absorption in the mTAL. The EP1 receptor is coupled to increased cell [Ca2+]. EP1 mRNA expression is restricted to the CD, and receptor activation inhibits Na+ absorption. PGE2 also increases cAMP generation in the cortical thick ascending limb and CD; this may be due to EP4 receptor activation. EP4 mRNA is readily detected in the CD with little detectable EP2 expression. The EP4 receptor appears to be expressed both on luminal and basolateral membranes. EP4 receptor activation also may contribute to the regulation of renin release by the juxtaglomerular apparatus. The consequences of renal EP-receptor activation for salt and water balance may be determined by the relative renal expression of each of these receptors.

Cloning, expression, and regulation of rabbit cyclooxygenase-2 in renal medullary interstitial cells.

Prostaglandin synthesis requires cyclooxygenase-1 (COX1) or -2 (COX2), which mediate the conversion of arachidonate to prostaglandin H2. COX1 is the predominant constitutive isoform, whereas COX2 expression is typically low. In the present studies we cloned rabbit COX2 and determined its distribution in unstimulated tissues. Screening rabbit eye and uterine libraries yielded two cDNAs containing identical inserts with a 1,812-nucleotide open-reading frame. This encoded a 604-amino acid polypeptide, 90% identical to human, rat, and mouse COX2. Expression of the rabbit COX2 in HEK-293 cells enhanced prostanoid synthesis. Constitutive COX2 mRNA expression was highest in kidney and urinary bladder. COX2 expression was primarily in renal outer medullary interstitial cells with cortical expression in macula densa. In cultured medullary interstitial cells, COX2 mRNA predominated, with little COX1 expression. Interstitial cell COX2 mRNA but not COX1 was induced by phorbol ester and epidermal growth factor but suppressed by dexamethasone. Phorbol ester also upregulated immunoreactive COX2. Constitutive COX2 in these tissues has important implications for side effects of COX2-selective inhibitors.

Intrarenal distribution of rabbit PKC zeta.

To elucidate roles of protein kinase C (PKC) zeta in rabbit kidney, PKC zeta was cloned from a rabbit kidney cortex cDNA library. Sequencing revealed a 2113 m insert with an open reading frame encoding a protein of 591 amino acids. The predicted amino acid sequence is 93.7% identical with rat PKC zeta. In situ hybridization in rabbit kidney with a riboprobe generated from the cloned cDNA, showed PKC zeta mRNA is highly expressed in proximal tubule, thick limb, and collecting duct. No message was detected over glomerular cells. Immunohistochemical studies using a monoclonal antibody against PKC zeta confirmed this distribution with low expression in vascular elements and high expression in tubule epithelium. Confocal microscopy showed diffuse cytosolic immunoreactivity in confluent cultured cortical collecting ducts (CCDs). However, in subconfluent cells, immunoreactivity was restricted to the peri-nuclear area. This differential distribution of PKC zeta in the CCD suggests that PKC zeta action be involved in growth and differentiation of the collecting duct. In conclusion, PKC zeta is differentially expressed in the rabbit kidney with high expression in the tubule epithelium and little expression in vascular elements. These studies suggest an important role for PKC zeta along the nephron.

[Effect of microinjection of angiotensin II into area postrema on renal sodium excretion].

It has been known that area postrema (AP) possesses angiotensin II (A II) receptors and senses directly the change of blood A II level. The effect of microinjection of A II into the AP on renal sodium excretion was studied in the present investigation. Our experimental results show that microinjection of A II (2, 20 ng) increases GFR, RPF and UNaV (P < 0.05). These changes can be abolished by A II antagonist, saralatin and renal denervation (P < 0.05). However microinjection of A II (20 ng) into NTS produces no such changes. These results strongly suggest that the A II induced changes of renal hemodynamics and urine sodium excretion are mediated through AP.

[The mechanism of renal hyperperfusion induced by hyperglycemia].

Using whole body clearance technique as well as isolated perfused rat kidney (IPRK). We studied the effect of hyperglycemia on renal hemodynamics and the possible mechanism involved. Hyperglycemia increased renal plasma flow (RPF) and glomerular filtration rate (GFR). In nonfiltering isolated perfused rat kidney or after adding furosemide to the perfusate, both techniques were believed to abolish the tubuloglomerular feedback, the renal hemodynamic changes induced by hyperglycemia disappeared, but adding sodium nitroprusside increased RPF and decreased renal vascular resistance (RVR). D-alpha-methyl-glucoside, a glucose derivative, increased RPF and GFR in IPRK, but had no influence on renal hemodynamics in whole body clearance study. Hemoglobin, which could block the action of endothelium--derived relaxing factor (EDRF), did not change the effects of hyperglycemia on renal hemodynamics in IPRK. These results indicated that hyperglycemia could directly induce hyperperfusion and hyperfiltration, which is mainly mediated by suppression of tubuloglomerular feedback. EDRF do not play the major role in the changes of hemodynamics induced by hyperglycemia.