A double-blind, placebo-controlled, crossover trial comparing the effects of amiloride and hydrochlorothiazide on glucose tolerance in patients with essential hypertension.

Hypertension guidelines advise limiting the dose of thiazide diuretics and avoiding combination with ß-blockade, because of increased risk of diabetes mellitus. We tested whether changes in the 2-hour oral glucose tolerance test could be detected after 4 weeks of treatment with a thiazide and could be avoided by switching to amiloride. Two double-blind, placebo-controlled, crossover studies were performed. In study 1 (41 patients), we found that changes in glucose during a 2-hour oral glucose tolerance test could be detected after 4 weeks of treatment with bendroflumethiazide. In study 2, 37 patients with essential hypertension received, in random order, 4 weeks of once-daily treatment with hydrochlorothiazide (HCTZ) 25 to 50 mg, nebivolol 5 to 10 mg, combination (HCTZ 25-50 mg+nebivolol 5-10 mg), amiloride (10-20 mg), and placebo. Each drug was force titrated at 2 weeks and separated by a 4-week placebo washout. At each visit, we recorded blood pressure and performed a 75-g oral glucose tolerance test. Primary outcome was the difference in glucose (over the 2 hours of the oral glucose tolerance test) between 0 and 4 weeks, when HCTZ and amiloride were compared by repeated-measures analysis. For similar blood pressure reductions, there were opposite changes in glucose between the 2 diuretics (P<0.0001). Nebivolol did not impair glucose tolerance, either alone or in combination. There was a negative correlation between Δpotassium and Δ2-hour glucose (r=-0.28; P<0.0001). In 2 crossover studies, 4 weeks of treatment with a thiazide diuretic impaired glucose tolerance. No impairment was seen with K(+)-sparing diuretic or ß(1)-selective blockade. Substitution or addition of amiloride may be the solution to preventing thiazide-induced diabetes mellitus.

Evaluation of the sensitivity and specificity of (11)C-metomidate positron emission tomography (PET)-CT for lateralizing aldosterone secretion by Conn's adenomas.

CONTEXT: Identification of unilateral aldosterone-producing (Conn's) adenomas has traditionally required lateralization by the invasive and technically difficult procedure of adrenal vein sampling (AVS). (11)C-metomidate, a potent inhibitor of adrenal steroidogenic enzymes, is a positron emission tomography (PET) radiotracer that is selectively accumulated by Conn's adenomas. OBJECTIVE: The objective of the study was to compare the sensitivity and specificity of (11)C-metomidate PET-computed tomography (CT) against the current gold standard of AVS. DESIGN: The design of the study was within-patient comparison of diagnostic techniques. SETTING: The study was conducted at a single center-university teaching hospital. PATIENTS: Thirty-nine patients with primary hyperaldosteronism (PHA) and five with nonfunctioning adenomas (incidentalomas) participated in the study. INTERVENTION(S): The first six PHA patients were studied on three occasions to determine whether steroid pretreatment reduced (11)C-metomidate uptake by normal adrenal. Subsequent patients received dexamethasone for 3 d prior to injection of (11)C-metomidate 150-500 MBq. MAIN OUTCOME MEASURE(S): Maximum standardized uptake values (SUV(max)) over regions of interest determined from 35-45 min after injection were measured. RESULTS: Dexamethasone increased tumor to normal adrenal SUV(max) ratio by 25.6 ± 5.0% (P < 0.01). PET-CT visualized subcentimeter adenomas and distinguished hot from cold adenomas within a gland. In 25 patients with PHA and AVS lateralization to the side of an adenoma, SUV(max) over tumor (mean ± sem) of 21.7 ± 1.6 was greater than over normal adrenal, 13.8 ± 0.6 (P = 0.00003); this difference was absent in 10 patients without lateralization on AVS (P = 0.28) and in four of five incidentalomas. On receiver-operator characteristics analysis, an SUV(max) ratio of 1.25:1 provided a specificity of 87% [95% confidence interval (69, 104)] and sensitivity of 76% (59, 93); in tumors with SUV(max) greater than 17, the specificity rose to 100%. CONCLUSIONS: (11)C-metomidate PET-CT is a sensitive and specific noninvasive alternative to AVS in the management of PHA.

Investigating the function of an aldosterone response pathway in primary human adrenocortical cells obtained from Conn's and phaeochromocytoma patients.

The components of the classical renal aldosterone response pathway are expressed in human adrenocortical cells; however, studies in H295R cells have shown that pharmacological manipulation of this pathway has no effect on aldosterone production. We have characterised aldosterone and cortisol production by primary human adrenocortical cells and tested the hypothesis that a mineralocorticoid response pathway modulates aldosterone secretion. Aldosterone production by cells obtained from normal adrenal cortex was stimulated by angiotensin II, extracellular K(+) and a reduction in extracellular Na(+). Conn's adenoma cells, in comparison, produced higher aldosterone/cortisol ratios and were less responsive to angiotensin II and extracellular Na(+). Close coupling of aldosterone and cortisol secretion was observed in all adrenocortical cells. The mineralocorticoid receptor antagonists, eplerenone and potassium canrenoate, had no significant effect on aldosterone or cortisol production. In contrast, the glucocorticoid receptor antagonist, mifepristone, and the Na(+) uptake inhibitor, amiloride, had significant inhibitory effects on steroid production. Our current experiments do not support the hypothesis that an adrenal aldosterone-response pathway mediates the negative feedback of aldosterone on its own release, but do raise interest in the glucocorticoid receptor and downstream targets of the mineralocorticoid receptor as mediators of corticosteroid production.

The effects of urotensin II and urantide on forearm blood flow and systemic haemodynamics in humans.

AIMS: (i) To compare the effects of intra-arterial administration of urotensin II in patients with CVD with healthy volunteers, and (ii) to study the haemodynamic effects of intra-arterial infusion of the urotensin II receptor antagonist, urantide. METHODS: Ten healthy volunteers and 10 patients with CVD received a dose-ramped brachial artery infusion of urotensin II. A further six healthy male volunteers received a prolonged urotensin II infusion and 11 healthy male volunteers received a dose-ramped infusion of urantide. Forearm blood flow (FBF) was measured every 20 min and blood pressure and heart rate were assessed every 20 min. RESULTS: In healthy volunteers and patients with CVD, intra-arterial infusion of urotensin II had no effect on FBF ratio. A dose-ramped infusion of urantide similarly had no effect on FBF ratio. During dose-ramped infusions of urotensin II and urantide, systolic and mean arterial blood pressure increased significantly. In healthy volunteers, urotensin II and urantide, respectively, increased systolic blood pressure from 133 +/- 6 to 137 +/- 5 mmHg (P < 0.01) and from 113 +/- 4 to 120 +/- 4 mmHg (P < 0.01). In patients with CVD, heart rate also significantly increased during dose-ramped infusion of urotensin II from 59 +/- 3 to 62 +/- 4 bpm (P < 0.05). CONCLUSIONS: We have shown no in vivo effect of urotensin II or urantide on human forearm resistance vessels. Previous discrepancies do not seem to relate to either the age or CVD status of subjects. Changes in systemic cardiovascular haemodynamics during the dose-ramped infusion studies are unlikely to be caused by urotensin II receptor modulation.

Expression of the epithelial Na(+) channel and other components of an aldosterone response pathway in human adrenocortical cells.

We have unexpectedly found expression of the epithelial Na(+) channel (ENaC) in human adrenocortical cells and tested the hypothesis that these cells contain the components of an aldosterone response pathway. Tissue was obtained from patients undergoing adrenalectomy and mRNA and protein expression of recognised components of an aldosterone-response pathway were determined by RT-PCR and Western blotting. The effects of mineralocorticoid receptor agonists and antagonists, amiloride analogues, and extracellular Na(+) on basal and stimulated aldosterone release from immortalised (H295R) cells were determined by radioimmunoassay. Expression of mRNA for alpha-, beta- and gamma-subunits of ENaC, the mineralocorticoid receptor, Nedd4L, Sgk1 and 11beta hydroxysteroid dehydrogenase type II was confirmed in human adrenal cortex. Using Western blotting alpha-, beta- and gamma-ENaC expression was demonstrated in adrenocortical cells. Measurements of 24 h aldosterone release from H295R cells showed stimulation by K(+) and angiotensin II, suppression by both Na(+) and high-concentration 5-(N-ethyl-N-isopropyl) amiloride (EIPA, blocker of Na(+)-H(+) exchange) and no change with benzamil (ENaC blocker). (22)Na-uptake into H295R cells was inhibited by EIPA, but not by benzamil. Our experiments suggest that the components of an aldosterone response pathway are present in human adrenal cortex. Studies in H295R cells, however, suggest that ENaC is not an important mediator of (22)Na-uptake or aldosterone production. Further studies are required to determine the importance of an adrenal aldosterone response pathway.

Divergent cell signaling after short-term intensified endurance training in human skeletal muscle.

Endurance training represents one extreme in the continuum of skeletal muscle plasticity. The molecular signals elicited in response to acute and chronic exercise and the integration of multiple intracellular pathways are incompletely understood. We determined the effect of 10 days of intensified cycle training on signal transduction in nine inactive males in response to a 1-h acute bout of cycling at the same absolute workload (164 +/- 9 W). Muscle biopsies were taken at rest and immediately and 3 h after the acute exercise. The metabolic signaling pathways, including AMP-activated protein kinase (AMPK) and mammalian target of rapamycin (mTOR), demonstrated divergent regulation by exercise after training. AMPK phosphorylation increased in response to exercise ( approximately 16-fold; P < 0.05), which was abrogated posttraining (P < 0.01). In contrast, mTOR phosphorylation increased in response to exercise ( approximately 2-fold; P < 0.01), which was augmented posttraining (P < 0.01) in the presence of increased mTOR expression (P < 0.05). Exercise elicited divergent effects on mitogen-activated protein kinase (MAPK) pathways after training, with exercise-induced extracellular signal-regulated kinase (ERK) 1/2 phosphorylation being abolished (P < 0.01) and p38 MAPK maintained. Finally, calmodulin kinase II (CaMKII) exercise-induced phosphorylation and activity were maintained (P < 0.01), despite increased expression ( approximately 2-fold; P < 0.05). In conclusion, 10 days of intensified endurance training attenuated AMPK, ERK1/2, and mTOR, but not CaMKII and p38 MAPK signaling, highlighting molecular pathways important for rapid functional adaptations and maintenance in response to intensified endurance exercise and training.

Aldosterone stimulates active Na+ transport in rabbit urinary bladder by both genomic and non-genomic processes.

The ability of aldosterone to stimulate Na+ transport in a range of epithelial tissues has been known for many years. Early work suggested that aldosterone had a delayed action operating by transcriptional up-regulation of proteins such as the epithelial Na+ channel. However more recent data has suggested that the hormone has a short-term non-genomic action. In this paper we investigate short and long-term actions of aldosterone on Na+ transport in the rabbit urinary bladder. We have shown that aldosterone stimulates epithelial Na+ channel activity, as measured by the amiloride-sensitive short-circuit current over a 3.75 h period and that this action is potentiated by cAMP. Using reverse transcriptase-polymerase chain reaction we have shown that aldosterone and forskolin in combination up-regulate mRNA synthesis for the beta- and gamma-subunits of the epithelial Na+ channel. Using Western blotting we have shown in the case of the beta-subunit that a corresponding increase in channel protein occurs. We have also demonstrated that aldosterone in the presence of inhibitors of phosphodiesterase can stimulate the short-circuit current across rabbit bladder epithelium over a 20 min period. An explanation for the synergistic interaction between aldosterone and cAMP is provided. We have shown that aldosterone can increase cAMP levels within urothelial cells over a 4 min period. We propose that this represents a non-genomic action of the steroid hormone.

Regulation of Na+ channel density at the apical surface of rabbit urinary bladder epithelium.

We have investigated the effects of various manipulations on Na(+) transport across the rabbit urinary bladder epithelium. After bladders were mounted in Ussing chambers there was a spontaneous and significant (>4-fold) increase in amiloride-sensitive short-circuit current (equivalent to net Na(+) transport) over a 6-h period. The increase in current was almost abolished by brefeldin A, an inhibitor of anterograde vesicular transport, and reduced after a 3-h delay by cycloheximide, an inhibitor of protein synthesis. The spontaneous increase in short-circuit current was potentiated by treatment of bladders with either forskolin, which causes an elevation in cAMP levels, or aldosterone. Acting together, these two agents produced a significant synergistic effect on short-circuit current. The short-circuit current recovered rapidly after reduction in intracellular Na(+) levels, achieved either by lowering the extracellular Na(+) concentration or blockade of epithelial Na(+) channels with the sulphydryl modifying reagent p-chloromercuribenzenesulphonic acid (PCMBS). Recovery after PCMBS treatment was partially sensitive to brefeldin A. Short-circuit current saturated as the extracellular Na(+) concentration was increased (EC(50) = 51 mM). Saturation occurred over a range of Na(+) concentrations in which single channel permeability is known to remain constant, indicating that it depends on a reduction in epithelial Na(+) channel density at the apical plasma membrane. Exposure of bladders to a high Na(+) concentration caused an increase in endocytotic activity, detected through an increase in the uptake of the fluid-phase marker fluorescein isothiocyanate (FITC)-dextran into vesicles located beneath the apical plasma membrane. We conclude that the urinary bladder epithelium is able to respond rapidly and efficiently to changes in its environment by regulating the density of epithelial Na(+) channels in its apical surface.