Pharmacokinetics of nateglinide and its metabolites in subjects with type 2 diabetes mellitus and renal failure.

AIMS: We evaluated the benefits and safety of nateglinide, a novel oral hypoglycemic agent, in type 2 diabetes patients with renal failure. METHODS: Single-dose pharmacokinetics were studied in 8 patients with type 2 diabetes and a low creatinine clearance (range 1.8-16.5 ml/min/1.73 m2) up to 6 hours after 90 mg nateglinide administration. Next, we treated another group of 8 patients undergoing regular hemodialysis with nateglinide 90 mg/day for 1-3 months. The effect of hemodialysis on metabolite accumulation was then tested. RESULTS: After a single 90 mg dose, nateglinide significantly increased the post-prandial secretion of insulin and thereby reduced plasma glucose levels. Mean pharmacokinetic parameters (AUC(0-6) 10.45 mg/l/h; t(1/2) 1.89 h, Cl/F 10.19 l/h) were comparable with those reported in healthy subjects. A much larger AUC value than those previously reported of M1, a major metabolite in the urine of healthy subjects, was observed, and the plasma concentration of M1 did not decline up to 6 hours after. In patients treated on a regular basis, there was marked accumulation of M1, while nateglinide could not be detected 24 hours after the last dose. Plasma M1 levels were significantly reduced by the hemodialysis sessions. CONCLUSIONS: Single 90 mg dose of nateglinide was safe and effective in patients with renal failure. However, repeated administrations could cause prolonged hypoglycemia due to accumulation of M1, which is known to have a modest hypoglycemic activity. Hemodialysis may help to eliminate excessive accumulation of M1.

Significantly rapid relief from steroid-resistant nephrotic syndrome by LDL apheresis compared with steroid monotherapy.

Rapid amelioration of hypercholesterolemia by LDL apheresis (LDL-A) was performed for long-standing nephrotic syndrome (NS) with hyperlipidemia due to focal segmental glomerulosclerosis (FGS) and the clinical data and prognosis were compared between LDL-A-treated and nontreated groups. Seventeen steroid-resistant NS patients treated with LDL-A (LDL-A group) and 10 NS patients treated with steroids only (steroid-monotherapy (SM) group) were compared. Serum cholesterol and phospholipid levels were significantly lowered only in the LDL-A group (p < 0.01, respectively). The LDL-A group showed a significant decrease of urinary protein (UP, p < 0.01) and increase of serum albumin (p < 0.05). Average time needed to achieve a decrease of UP to less than nephrotic range (< 3.5 g/day) was significantly shorter in the LDL-A group than in the SM group (p < 0.01). Although this is not a prospective study, it is highly expected that a rapid improvement of hypercholesterolemia by LDL-A in steroid-resistant NS will provide more rapid relief from NS than steroid therapy alone.

Association of endothelial dysfunction with sulfur amino acid metabolism in chronic renal failure.

Moderate hyperhomocysteinemia and endothelial dysfunction are consistent findings in uremic patients. Although an exceedingly high incidence of cardiovascular disease and stroke has been shown in dialysis patients, several traditional risk factors are relatively limited predictors. Hyperhomocysteinemia could be a principal candidate for endothelial dysfunction. Recent findings suggest that hyperhomocysteinemia may impair endothelial function by the generation of oxygen species and decreased nitric oxide (NO) bioavailability. However, the precise mechanisms underlying the link between hyperhomocysteinemia and impaired endothelial function in chronic renal failure remain unclear. Endothelial function was evaluated by the response to reactive hyperemia and donor of NO. We observed impairment in both endothelium-dependent and endothelium-independent vasodilation in dialysis patients. These data suggest that patients with chronic renal failure may have defective NO-mediated function in the endothelium and smooth muscle of vessels. Most reports have shown only impairment of endothelium-dependent vasodilation, whereas another report observed impaired smooth muscle function and intact endothelial function. Only a few previous observations included a full set of vascular function data, such as baseline vessel diameter, reactive hyperemia, and responses of endothelium to hyperemia and NO donor, although all these observations could be essential for comparison with other reports. Treatment with folic acid was reported to reduce plasma homocysteine levels, but not to normal levels, and failed to improve impaired endothelial function in patients in a predialysis phase and on maintenance dialysis therapy. Another investigation, directed at reducing homocysteine levels in earlier stages of renal failure, may be necessary to clarify the link between hyperhomocysteinemia and endothelial function.

[Perioperative bleeding tendency in a hemodialysis patient during gastrectomy under total intravenous anesthesia using propofol infusion].

A 64-year-old female receiving hemodialysis (HD) underwent subtotal gastrectomy for gastric cancer under total intravenous anesthesia. Anesthesia was performed using continuous infusion of propofol (5-8 mg.kg-1.h-1), buprenorphine i.v. (2.5 micrograms.kg-1), 2% mepivacaine epidural infusion (7 ml.h-1) and appropriate doses of vecuronium. The blood pressure and heart rate were stable within 120% of the preoperative level. However, 3 and half hours after propofol anesthesia, increased bleeding from the surgical field was observed. The activated clotting time (ACT) was 144 seconds. Furthermore, at the end of the operation (5 hours after propofol anesthesia), the ACT (219 sec), PT (14.8 sec), PT-INR (1.94) and APTT (102.5 sec) were significantly prolonged. The platelet count was unchanged. The intraoperative total bleeding was 844 g. The total propofol infusion time and dose were 310 minutes and 1,580 mg, respectively. Immediate recovery with spontaneous ventilation was observed. Postoperative bleeding from the wound continued. Finally, 7 hours after the surgery, the bleeding ceased and the ACT (125 sec), PT (12.4 sec), PT-INR (1.34) and APTT (22.5 sec) were normalized. The total postoperative bleeding was 404 g. Despite the advantage of short-acting anesthetic agent, we suspect that propofol induced the bleeding tendency via platelet inhibition. This platelet inhibition may gradually increase with time and the dose of propofol. We should utilize propofol cautiously for patients receiving HD or with bleeding tendency.

Low density lipoprotein apheresis therapy for steroid-resistant nephrotic syndrome. Kansai-FGS-Apheresis Treatment (K-FLAT) Study Group.

BACKGROUND: The pathogenic role of hyperlipidemia in long-standing nephrotic syndrome (NS) is known to be responsible for both the progression of glomerulosclerosis and tubulointerstitial injury, especially in focal segmental glomerulosclerosis (FGS). METHODS: Aggressive lipid lowering treatment by low density lipoprotein (LDL) apheresis (LDL-A) using a dextran sulfate cellulose column to treat patients with steroid-resistant or frequently recurrent severe NS was performed first without fixing the protocol in eight patients with FGS and one with minimal change nephrotic syndrome (MCNS). The period of NS before LDL-A, number and average intervals of LDL-A until the end of the therapy, and the prognosis were investigated. Next, a multicenter study with a fixed protocol of LDL-A treatment was designed in combination with steroid therapy for treatment twice a week for three weeks and weekly for six weeks, and was performed in 17 patients with FGS. The effects on the state of NS in addition to the change of urinary eicosanoid metabolites and remission rates were evaluated. RESULTS: In the preliminary study, along with a rapid improvement of hyperlipidemia, a high incidence of remission was achieved by LDL-A performed at relatively short intervals. In the multicenter study with a fixed protocol, there was a significant decrease of urinary protein (P < 0.001) and increase of serum albumin (P < 0.02) as well as a decrease of thromboxane B2 (TXB2) excretion (P < 0.05) after the treatment. Urinary excretion of TXB2 was significantly reduced after LDL-A (P < 0.05). The rate of entering into complete or incomplete remission was 71% with a relatively short duration of nephrotic-range proteinuria using the LDL-A therapy in comparison with steroid therapy alone. CONCLUSION: The rapid improvement of hypercholesterolemia with LDL-A treatment may provide a new approach for a high rate of improvement in the degree of NS in steroid-resistant NS of FGS and MCNS.

Response to hypertonicity in mesothelial cells: role of Na+/myo-inositol co-transporter.

BACKGROUND: During peritoneal dialysis, the peritoneal mesothelium is exposed continually to hypertonic dialysates. The purpose of this study is to see if rat mesothelial cells have an osmoregulatory mechanism to adapt to hypertonic environment. METHODS: The intracellular content of organic osmolytes was measured by HPLC methods. Myo-inositol transport activity was measured by Na+-dependent uptake of [3H]myo-inositol. mRNA abundance for the Na+/myo-inositol co-transporter (SMIT) was examined by Northern and slot-blot analyses. RESULTS: In isotonic mesothelial cells, only myo-inositol could be detected. After switching to hypertonic medium made by addition of NaCl, myo-inositol content gradually increased and peaked at 48 h after the switch. The myo-inositol content in hypertonic cells increased > 7-fold over the value in isotonic cells. The contents of betaine and glycerophosphorylcholine (GPC) also increased but were less than that of myo-inositol. Sorbitol was not accumulated in this condition. When glucose was used to increase medium osmolality, all of the four osmolytes were increased by hypertonicity (myo-inositol > sorbitol > GPC > betaine). Thus, myo-inositol is the most abundant osmolyte in the mesothelial cells. Na+-dependent myo-inositol uptake in hypertonic cells was approximately 7-fold the uptake in isotonic cells, reaching a maximum 16 h after switching to a hypertonic medium. The uptake rate increased as medium osmolality increased from 300 to 500 mosm/kg. SMIT mRNA rapidly increased after increasing medium osmolality, reaching a maximum 8 h after the switch. The relative increase in the mRNA abundance was approximately 11 times isotonic levels. CONCLUSIONS: Mesothelial cells respond to extracellular hypertonicity by increasing SMIT mRNA abundance, myo-inositol transport activity and accumulating myo-inositol into the cells.

[Nedaplatin and etoposide combination chemotherapy in a patient with small cell carcinoma undergoing hemodialysis].

A 61-year-old man with chronic renal failure caused by polycystic kidney disease requiring hemodialysis three times weekly developed small cell carcinoma of the lung. The patient received combination chemotherapy with nedaplatin (50 mg) and etoposide (50 mg). Blood levels were monitored, showing that nedaplatin was more dialyzable than cisplatin. The patient achieved a complete response. These results suggest that nedaplatin-etoposide combination chemotherapy may be safer than cisplatin-containing regimen for patients with chronic renal failure hemodialysis and that a satisfactory response can be expected.

[Paradoxical effect of L-arginine on nitric oxide (NO) synthesis and histopathological changes in 5/6 nephrectomized SD rats].

Whether L-Arginine (L-ARG) ameliorates or aggravates renal function and histopathological changes in several models of renal disease remains controversial as L-ARG is the substrate for nitric oxide (NO) synthase as well as the precursor of proline and polyamines which cause renal fibrosis. These ambiguous results might be attributed to differences in the dose and period of L-ARG administration and the animal model used in each observation. Therefore, we tested the dose-dependent effect of L-ARG on mean blood pressure (MBP), 24-hour urinary excretion of protein (UP), NO metabolites (NO2(-) + NO3-) and cyclic GMP (cGMP), plasma asymmetrical dimethylarginine (ADMA), glomerular sclerosis index (SI) and % interstitial fibrosis area (%INT) in 5/6 nephrectomized SD rats. These 5/6 nephrectomized SD rats were divided into 4 groups: 1. L-ARG 0.2 g/kg/day (0.2 g ARG), 2. L-ARG 1 g/kg/day (1 g ARG), 3. L-ARG 2 g/kg/day (2 g ARG), 4. No administration of L-ARG(ARG(-)). Compared with ARG(-)MBP, UP and ADMA were significantly decreased and NO2(-) + NO3-, cGMP were significantly increased in the 0.2 g ARG. SI group and %INT were significantly increased in the 2 g ARG group and decreased in the 0.2 g ARG group. A small dose of L-ARG ameliorated glomerulosclerosis and interstitial fibrosis while a larger dose did not. SI, %INT and ADMA were inversely correlated with NO2(-) + NO3-. These data suggested that renal NO synthesis might attenuate glomerulosclerosis and interstitial fibrosis and the rise in ADMA and L-ARG might cause the decrease in NO.

[Perioperative management for nephrectomy in a long-term hemodialysis patient with anticoagulants for coronary stent].

A 53-year old man on long-term hemodialysis (HD) with anticoagulant therapy was scheduled for nephrectomy due to renal cell carcinoma. Two months before surgery, a coronary stent had been placed due to right coronary artery disease. One week before surgery, percutaneous transmural coronary angioplasty (PTCA) was performed for unstable angina. Aggressive oral antiplatelet therapy (aspirin and ticlopidine) was absolutely required to maintain patency. Following withdrawal of the antiplatelets, unfractionated heparin (UFH) was titrated to an activated partial thromboplastin time (APTT) of 1.5 times greater than the control value. Maintenance UFH (800 U.h-1) was continued until the time of arrival in the operation room (activated clotting time (ACT) was 166 seconds). One hour after arrival, reduced dose of UFH (200 U.h-1) was reinfused, and ACT was 121 140 seconds. Hemodynamic change was minimized using balanced general anesthesia (nitrous oxide-isoflurane, fentanyl, midazolam and vecuronium) accompanied by nitroglycerin and diltiazem. There was no ischemic change on ECG or transesophageal echocardiography. Following surgery, the UFH dose was augmented (400 U.h-1), and the maintenance dose was attained 11 hours after surgery. HD on the second postoperative day was performed uneventfully. This hemodynamic stability might be come from the no water removal. Fourteen days after surgery, the patient was discharged without hemorrhagic complications or clinical ischemic events. We conclude that perioperative UFH infusion is not contraindicated for dialysis patient if strict ACT control is maintained.

Effects of inhibition of myo-inositol transport on MDCK cells under hypertonic environment.

To investigate the role of myo-inositol under hypertonic conditions, we examined the effects of inhibition of myo-inositol transport in Madin-Darby canine kidney (MDCK) cells using an analog of myo-inositol, 2-O,C-methylene-myo-inositol (MMI). We first characterized the inhibitory effects of MMI on myo-inositol transport in MDCK cells. The Na+-dependent component of [3H] myo-inositol uptake was inhibited by MMI in a concentration-dependent manner, although MMI did not inhibit the activities of the betaine transporter and system A neutral amino acid transporter. We found decreased affinity for myo-inositol in the presence of MMI, whereas the maximal velocity (Vmax) of the transporter did not change. Thus MMI behaves as a competitive inhibitor of myo-inositol transport with a relatively high inhibition constant (K(i)) value (1.6 mM). Myo-inositol content in hypertonic MDCK cells was markedly reduced in the presence of 5 mM MMI, but MMI itself did not accumulate in these cells. The hypertonic cells began to detach in the presence of MMI 3 days after increasing medium osmolality, whereas MMI did not affect the cells in isotonic medium. We also examined the effects of MMI on colony-forming efficiency of MDCK cells. MMI decreased colony-forming efficiency in a concentration-dependent manner, and addition of myo-inositol returned the efficiency to the value without MMI. Addition of betaine also increased colony-forming efficiency in the presence of MMI. These results indicate that myo-inositol plays an important role in survival and growth under hypertonic environment.

NaCl and/or urea infusion fails to increase renal inner medullary myo-inositol in protein-deprived rats.

As we recently demonstrated that in potassium depletion a decrease in inner medullary organic osmolytes might precede and cause a renal concentrating defect, we hypothesized that in the protein deprivation the same mechanism may occur. To clarify the relationship between renal medullary organic osmolytes and urine concentration defects during protein deprivation, we examined the effect of protein malnutrition on organic osmolyte content after water deprivation or sodium and/or urea infusion. Water deprivation did not restore urine urea and osmolality or tissue sodium and urea in protein-deprived rats to control levels. NaCl infusion only increased urinary and medullary Na. Urea infusion increased medullary urea but not urine urea. NaCl plus urea infusion increased only urinary sodium and urea. Regardless of the protocols of hyperosmolality used, protein deprivation significantly decreased the medullary contents of myo-inositol and taurine and the level of sodium-dependent myo-inositol transporter mRNA. We conclude that factors other than NaCl and urea but associated with protein feeding are responsible for the decreased accumulation of organic osmolytes.

Influence of magnesium deficiency on concentration of calcium in soft tissue of uremic rats.

The influence of magnesium (Mg) deficiency on the concentration of calcium (Ca) in the aorta, heart, and kidney was evaluated in uremic rats. A total of 32 rats were randomly assigned to two groups: one group made uremic by the 5/6 nephrectomy method, and the other serving as sham-operated controls. Both groups were randomly assigned to two subgroups: one group given a Mg-deficient diet and the other fed a Mg-supplemented diet. After 12 weeks on the regimen, all animals were sacrificed. In Mg-supplemented uremic rats, the concentration of Ca in the aorta was higher than in Mg-supplemented control rats. The concentration of Ca in the aorta was further increased in Mg-deficient uremic rats. The concentrations of Ca in the heart and the kidney were also increased in Mg-deficient uremic rats, as compared with Mg-supplemented uremic rats. The concentration of Mg was decreased in the aorta and increased in the kidney of Mg-deficient rats. There was no significant influence of Mg deficiency on the concentration of phosphate in tissue. Results suggest that Mg deficiency in uremia may increase aortic calcification.

Potassium depletion modulates aldose reductase mRNA in rat renal inner medulla.

The organic osmolytes present in renal inner medullary cells balance the extracellular hyperosmolality and protect the cell against the effects of high salts and urea. We previously demonstrated that a renal concentrating defect due to potassium depletion was associated with a decrease in organic osmolytes including sorbitol. However, we could not determine whether a reduction in medullary organic osmolyte would be cause or effect of urine concentration defect associated with potassium depletion. We focused on the synthesis of sorbitol catalyzed by the enzyme, aldose reductase. To clarify whether the treatment of potassium depletion would affect aldose reductase when extracellular tonicity, and medullary sodium or potassium was maintained at the level of control rats, we administered a hypertonic solution of NaCl or KCl to potassium-depleted rats and evaluated aldose reductase enzymatic activity and mRNA abundance as well as the medullary contents of organic osmolytes. Either infusion significantly reduced tissue sodium content in potassium-depleted rats. With KCl infusion protocol but not that of NaCl, sorbitol as well as aldose reductase mRNA abundance increased to the control level. Medullary contents of other organic osmolytes exhibited a pattern similar to sorbitol. Data suggested that aldose reductase mRNA abundance was reduced in potassium depletion irrespective of medullary sodium content. A decrease in sorbitol level may precede a urinary concentrating defect. Our finding constitutes the first demonstration of the relationship between a potassium deficiency and the abundance of aldose reductase mRNA, an osmoregulatory protein in the kidney.

Effect of low dietary calcium intake on blood pressure and pressure natriuresis response in rats: a possible role of the renin-angiotensin system.

Dietary Ca is an important modulator of blood pressure in humans and rats. Since the kidney plays a key role in the pathogenesis of hypertension, the effects of a low Ca diet (0.01% Ca) on blood pressure and pressure natriuresis response were studied in normotensive Sprague-Dawley rats. In addition, a possible role of the renin-angiotensin system in the development of hypertension and an altered pressure natriuresis response resulting from low dietary Ca intake was examined. In the low Ca diet group, systolic blood pressure measured by the tail-cuff method was significantly higher than in the normal Ca diet group (1,1% Ca) 1 week after the diet (1 13.0 +/- 7.1 vs. 105.0 +/- 9.5mmHg, p < 0.05). After 4 weeks, the hypertension was more pronounced. Low dietary Ca intake significantly inhibited the water and sodium excretory responses to acute elevation of renal perfusion pressure by tightening an infrarenal aortic constriction. Treatment with an inhibitor of angiotensin-converting enzyme, captopril (30 mg/kg/day), completely abolished the elevation of blood pressure and attenuated the reduced pressure natriuresis response observed in Ca-deficient rats. Although plasma renin activity was not different between the low and normal Ca diet groups after the 2-week dietary regimen, the pressor response to angiotensin II was enhanced by 30% in the low Ca diet group and there was a significant difference in the pressor response between the two groups. These results suggest a possible involvement of the renin-angiotensin system in the development of hypertension and an inhibitory effect on the pressure natriuresis response caused by low dietary Ca intake, via an enhanced sensitivity to angiotensin II.

Aldose reductase and myo-inositol transporter mRNA are independently regulated in rat renal medulla.

During antidiuresis, renal papillary cells accumulate organic osmolytes preferentially over inorganic ions. It has been previously demonstrated that sodium infusion increased all of these organic osmolytes except myo-inositol (1). Conversely, urea infusion increased only glycerophosphorylcholine significantly. In addition to sodium and urea, potassium localized in tissue and urine influenced the composition of organic osmolytes. The goal of this study was to clarify how the level of mRNA of osmoregulatory protein is regulated by the extracellular solutes and how it affects the accumulation of organic osmolytes. To clarify the relationship between intra- or extracellular solutes and the regulation of Na/myo-inositol cotransporter and aldose reductase, mRNA of these osmo-regulatory proteins were determined in water-deprived sodium chloride-, potassium chloride-, and urea-loaded rats. Medullary content of sorbitol and myo-inositol, and aldose-reductase enzymatic activity were measured simultaneously in these animals. In water-deprived, sodium-loaded, and potassium-loaded rats, the inner medullary sorbitol content increased significantly in accordance with the rise in the enzymatic activity and the level of aldose reductase mRNA. In urea-loaded rats, both the sorbitol content and the level of aldose reductase mRNA were equal to that in hydrated rats. In the outer and inner medullary tissues, the level of myo-inositol transporter mRNA was increased in all hyperosmolality protocols, including urea infusion, which corresponded with the rise in myo-inositol content. In conclusion, potassium chloride infusion is as effective as water deprivation and sodium chloride infusion in raising the level of aldose reductase and myo-inositol transporter mRNA, whereas urea influenced only myo-inositol transporter. Although aldose reductase and myo-inositol transporter are osmoregulatory proteins in the renal medulla, the levels of aldose reductase and sodium-dependent myo-inositol transporter mRNA are regulated independently.

Effect of 1,25-dihydroxyvitamin D3 and diltiazem on tissue calcium in uremic rat.

The concentration of calcium was measured in the aorta, heart, and kidney of uremic rats treated with 100 ng/kg/day 1,25-dihydroxyvitamin D3 (1,25 D3) or 60 mg/kg/day diltiazem for 12 weeks. The concentration of calcium was increased in the aorta, heart, and kidney of uremic rats, and was further increased by administration of 1,25 D3. The 1,25 D3-induced increase in calcium in the aorta was inhibited by diltiazem, but this effect was not accompanied by a decrease in serum calcium x phosphate products. Diltiazem had no effect on the 1,25 D3-induced increase of calcium in the heart and kidney. Thus, in uremia 1,25 D3 may promote the calcification of the aorta; calcium antagonists may protect against calcification without a reduction in serum calcium x phosphate products.