Predicting severe pain after root canal therapy in the National Dental PBRN.

Some patients experience severe pain following root canal therapy (RCT) despite advancements in care. We sought to identify factors, which can be measured preoperatively, that predict this negative outcome so that future research may focus on preemptive steps to reduce postoperative pain intensity. Sixty-two practitioners (46 general dentists and 16 endodontists) who are members of the National Dental Practice-Based Research Network enrolled patients receiving RCT for this prospective observational study. Baseline data collected from patients and dentists were obtained before treatment. Severe postoperative pain was defined based on a rating of ≥7 on a scale from 0 (no pain) to 10 (pain as bad as can be) for the worst pain intensity experienced during the preceding week, and this was collected 1 wk after treatment. Multiple logistic regression analyses were used to develop and validate the model. A total of 708 patients were enrolled during a 6-m period. Pain intensity data were collected 1 wk postoperatively from 652 patients (92.1%), with 19.5% (n = 127) reporting severe pain. In multivariable modeling, baseline factors predicting severe postoperative pain included current pain intensity (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07 to 1.25; P = 0.0003), number of days in the past week that the subject was kept from their usual activities due to pain (OR, 1.32; 95% CI, 1.13 to 1.55; P = 0.0005), pain made worse by stress (OR, 2.55; 95% CI, 1.22 to 5.35; P = 0.0130), and a diagnosis of symptomatic apical periodontitis (OR, 1.63; 95% CI, 1.01 to 2.64; P = 0.0452). Among the factors that did not contribute to predicting severe postoperative pain were the dentist's specialty training, the patient's age and sex, the type of tooth, the presence of swelling, or other pulpal and apical endodontic diagnoses. Factors measured preoperatively were found to predict severe postoperative pain following RCT. Practitioners could use this information to better inform patients about RCT outcomes and possibly use different treatment strategies to manage their patients (Clinicaltrials.gov NCT01201681).

The bladder angiotensin system in female rats: response to infusions of angiotensin I and the angiotensin converting enzyme inhibitor enalaprilat.

PURPOSE: A local renin angiotensin (ANG) system has been identified in the bladder. To our knowledge little is known about this system. To define further the physiology of this system we performed this study. MATERIALS AND METHODS: The circulating and bladder tissue concentrations of ANG I and ANG II were examined in anesthetized Sprague-Dawley female rats in estrus, diestrus or pregnancy. Each was given an intravenous bolus infusion of ANG I, the ANG converting enzyme inhibitor enalaprilat or saline. RESULTS: The mean concentrations of ANG I and ANG II were markedly higher in bladder tissue than in whole blood at the highest levels in pregnancy. The concentration of ANG I and ANG II increased significantly in the bladder tissue and circulation after the ANG I infusion in estrus and diestrus. In pregnancy only circulatory ANG I increased, while circulatory ANG II, tissue ANG I and ANG II remained unchanged. Enalaprilat infusion was associated with an increased concentration of whole blood ANG I in all groups and decreased plasma ANG II in estrus and diestrus but not in pregnancy. The bladder tissue ANG I response was unchanged in all groups. Bladder tissue ANG II was decreased in estrus and diestrus but unchanged in pregnancy. CONCLUSIONS: These data support the hypothesis that ANG converting enzyme is deactivated and an alternate pathway is activated in pregnancy. The data also demonstrate that tissue absorption of ANG peptide is diminished in pregnancy. Compared with responses in similarly studied male rats the circulating conversion of ANG I to ANG II is delayed in female rats and responses to ANG converting enzyme inhibition are enhanced, thus, suggesting subtle differences in the sexes in the renin ANG system. Enalapril appears to have more effect at the tissue level in nonpregnant females than in pregnant females and male rats.

Effects of renal denervation on the sodium excretory actions of leptin in hypertensive rats.

BACKGROUND: Previous studies from this laboratory have reported a marked attenuation of the renal responses to pharmacologic doses of synthetic murine leptin infused in the spontaneously hypertensive rat (SHR) model compared with normotensive Sprague-Dawley and lean Zucker rat models. METHODS: In the present study, the hemodynamic and renal excretory effects of an intravenous bolus administration of pharmacologic doses of synthetic murine leptin were examined in groups of anesthetized SHR with unilateral nephrectomy and renal denervation or sham-denervation of the remaining kidney. RESULTS: In the SHR with acute renal denervation (N = 8), an intravenous bolus of 1600 microg/kg of leptin produced a significant twofold to fourfold elevation in sodium excretion but did not increase natriuresis in the sham-denervated group (N = 6). Chronic renal denervation of one-week duration (N = 8) was associated with qualitatively and quantitatively similar increases of sodium excretion in response to leptin administration. Mean arterial pressure remained unchanged in all groups after the administration of leptin. CONCLUSIONS: Collectively, these results are interpreted to suggest that the blunted natriuretic and diuretic responses to leptin observed in the SHR with intact renal nerves may be partially explained by the antinatriuretic effect of an enhanced baseline efferent renal sympathetic activity and/or leptin's stimulation of the sympathetic nervous system.

Modulation of renin secretion by atrial natriuretic factor prohormone fragment 31-67.

BACKGROUND: Earlier studies have indicated that the atrial natriuretic factor prohormone fragment 31-67 (Pro ANF31-67) has important effects for the promotion of sodium excretion and vasodilation in several animal species. However, the mechanisms for the natriuretic actions of Pro ANF31-67 are not completely defined. In the present study, the effects of synthetic Pro ANF31-67 on renin secretion were examined in sodium-depleted, anesthetized dogs with a single intact kidney (n = 5). METHODS: After 3 20-minute control renal clearance periods, synthetic dog Pro ANF31-67 was given intrarenally at a sustained dose of 0.03 microg/kg/min for 3 20-minute experimental intervals, and after discontinuation of the peptide infusion, 3 final 20-minute recovery periods were determined. RESULTS: Sustained intrarenal infusions of the Pro ANF31-67 produced striking decrements (p<0.05) in renin secretion, from a control value of 1418 +/- 243 to 401 +/- 223 ng of angiotensin I/min. This 66% fall in renin secretion was associated with significant (P < 0.05) increases in creatinine clearance (40%), renal blood flow (8%), urine flow (50%), and sodium excretion (17%). CONCLUSIONS: It is suggested that this inhibition of renin secretion was mediated, at least in part, in response to a ProANF31-67-induced increment in the sodium load delivered to the macula densa. An interaction of the peptide with the renal vascular receptor for suppression of renin release is also possible. ProANF31-67 may represent an important hormonal mechanism involved in the regulation of body-fluid balance.

Recommendations for endodontic referral among practitioners in a dental HMO.

This study assessed the effect of patients' presenting conditions on general practitioners' (GPs') self-reported endodontic referral patterns, and compared GPs' perceived indications for referral with those of endodontists. The study was based on a self-administered, confidential survey distributed to 79 GPs and 7 endodontists who provide care to members of one Dental HMO in the Pacific Northwest. GPs were most likely to recommend referral for teeth they felt needed surgical retreatment, but GPs and endodontists did not always agree on indications for referral. Compared with GPs, endodontists were more likely to recommend referral for patients with complex problems, but not necessarily technically difficult teeth. Compared with those with less experience, GPs with more than 10 yr both in dentistry and at this HMO were more likely to recommend (a) referring difficult cases rather than performing endodontic therapy themselves and (b) extracting perforated or root-fractured teeth prior to obturation rather than continuing treatment. Indications for referral that maximize favorable dental outcomes need to be identified.

Hemodynamic and renal effects of ProANF31-67 in hypertensive rats.

It has been demonstrated previously that the atrial natriuretic factor prohormone fragment 31-67 (ProANF31-67) circulates in animals and possesses natriuretic and vasodilating actions. Although the plasma levels of the peptide are reportedly elevated in patients with high blood pressure, its role and actions in hypertension are unknown. In the present study, synthetic human ProANF31-67 was infused intravenously at doses of 0, 10, 30, and 100 ng/kg/min into respective groups of anesthetized normotensive and spontaneously hypertensive rats. Mean arterial pressure (MAP), urine flow rate (UV), and sodium excretion (UNaV) were measured during two consecutive 30-min periods. In both strains of rats, reductions in MAP with ProANF31-67 were similar in magnitude and dose-related. Sodium excretion responses to the peptide infusions also were remarkably similar in both normotensive and hypertensive rats, and the responses demonstrated 3- to 5-fold (P < 0.05) increments compared to control at the doses of 10 and 30 ng/kg/min. However, in the two strains of rats, attenuation of natriuresis occurred with the highest infusion dose of 100 ng/kg/min and was probably related to the large decreases in MAP of 17-23 mmHg at this dose of the peptide. The present results indicate the ProANF31-67 has important hemodynamic and renal effects in hypertension and may represent one compensatory mechanism involved in this disease.

Renal effects of leptin in normotensive, hypertensive, and obese rats.

The hemodynamic, hormonal, and renal excretory effects of intravenous bolus administration of synthetic murine leptin were examined in groups of anesthetized normotensive (Sprague-Dawley), hypertensive (spontaneously hypertensive), and both lean and obese Zucker rats. In the normotensive animals (n = 8) an intravenous bolus of 400 microgram/kg of leptin produced a significant six- to sevenfold elevation in sodium excretion compared with controls (n = 8). The onset of natriuresis was delayed for approximately 30-45 min. Mean arterial pressure (MAP), creatinine clearance, plasma renin activity (PRA), and plasma aldosterone concentration (PAC) remained unchanged. In contrast, the hypertensive rats were refractory to the natriuretic effects of leptin when infused either with 400 (n = 8) or 1,600 (n = 8) microgram/kg. Also in these animals MAP, creatinine clearance, PRA, and PAC were unmodified. Finally, whereas lean Zucker rats (n = 8) responded very similarly to the Sprague-Dawley animals, the natriuretic effect of the hormone was attenuated in the obese Zucker groups. At 400 microgram/kg (n = 8) no natriuresis was elicited, but at 1,600 microgram/kg (n = 8) a modest but significant two- to threefold increment in sodium excretion was observed in the obese rats. In both Zucker groups, MAP, creatinine clearance, PRA, and PAC were unchanged. Collectively, these results demonstrate a significant natriuretic effect of exogenous leptin in the normal rat and a blunted saluretic response in hypertension and obesity. It is suggested that leptin may be a potential salt-excretory factor in normal rats and may function pathophysiologically in obesity and hypertension.

The urinary bladder angiotensin system: response to infusions of angiotensin I and angiotensin-converting enzyme inhibitors.

The circulating and urinary bladder tissue concentrations of angiotensin I (ANG I) and angiotensin II [ANG-(1-8)] were examined in anesthetized Sprague-Dawley male rats given an intravenous bolus infusion of either ANG I, the angiotensin-converting enzyme (ACE) inhibitors enalaprilat or ramiprilat, or saline. The mean concentrations of ANG I and ANG-(1-8) were markedly higher in the urinary bladder tissue than in whole blood. There was a significant increase in the concentration of ANG I and ANG-(1-8), both in the urinary bladder tissue and the circulation, after the ANG I infusion. Both ACE inhibitors were associated with an increase in the concentration of whole blood ANG I; however, tissue ANG I levels were significantly increased only following ACE inhibition with ramiprilat but not with enalaprilat. Both plasma and urinary bladder tissue ANG-(1-8) levels decreased significantly following ACE inhibition, but only with ramiprilat. The elevated urinary bladder tissue levels of ANG I and ANG-(1-8) at baseline, compared with circulating levels, and the maintenance of ANG-(1-8) in bladder tissue in the face of inhibition of the circulatory renin-angiotensin system with enalaprilat support the presence of an autocrine/paracrine renin-angiotensin system in the urinary bladder. Under the current experimental conditions, ramiprilat appears to have enhanced bladder activity compared with enalaprilat.

Growth variation of Scots pine across a pollution gradient on the Kola Peninsula, Russia.

Decadal exposure to emissions from a non-ferrous smelter has damaged the forest ecosystems surrounding the city of Monchegorsk located on the Kola Peninsula in northwestern Russia. We use the methods of tree-ring analysis to study the areal extent and timing of recent growth reductions of Scots pine (Pinus sylvestris L.) in the region surrounding the smelter in Monchegorsk. Reduced growth of Scots pine was observed up to 30 km southwest of the smelter. This directional gradient of forest damage is related to the dispersal of pollutants which is influenced by the prevailing northern winds and local topographic features. Old Scots pines (age 200 years +) appeared to be more sensitive than younger ones: growth reductions of old trees had started earlier and reductions were observed farther from the smelter than for younger trees. The findings are compared to a classification which describes the state of forest ecosystems based on the occurrence of certain plant species; the classification matched well with the observed growth trends. Pollution-induced changes in the climatic signal in tree-rings are also studied. The strong dependence of growth on mid-summer temperatures, typical for Scots pine on high latitudes, proved to be insensitive to effects of pollution. Changes in the climate-growth relationship took place decades after growth trends had started to decline.

The angiotensin II type 1 receptor antagonists. A new class of antihypertensive drugs.

The angiotensin II (AII) type 1 receptor antagonists represent a new pharmacologic class of drugs that are specifically designed to displace AII from its type 1 receptor subtype. These drugs antagonize AII-induced biologic actions, including smooth-muscle contraction, sympathetic pressor mechanisms, and aldosterone release. Initial clinical trials suggest that these drugs are effective in the treatment of essential hypertension and hypertensive patients with intrinsic renal disease. Thus, they are the newest addition to the therapeutic armamentarium for the treatment of hypertensive diseases. We review the developmental history and pharmacology of the AII type 1 receptor antagonists. We specifically discuss the following factors: mechanism(s) of action; members under clinical investigation; effects on renal function, salt and water excretion, and plasma renin activity, plasma AII type 1, and plasma aldosterone concentrations; and efficacy and safety. Given the demonstrable benefits of AII type 1 receptor blockade, these drugs should achieve broad utility in the treatment of hypertensive diseases.

Practical application of infection control in endodontics.

The transmission of infections in an endodontic practice is a significant concern for both patients and dental health care providers. This article offers a review and practical application of infection control methods in the practice of endodontics.

Effects of losartan on the renin-angiotensin-aldosterone axis in essential hypertension.

Twelve essential hypertensive patients were entered into a prospective study assessing the effect of losartan, a non-peptide specific angiotensin II receptor antagonist, on blood pressure, the renin-angiotensin-aldosterone axis and renal function. Specifically monitored prior to and following 12 weeks of therapy at 6 (peak) and 24 (trough) h after dosing, were blood pressure, plasma renin activity (PRA), plasma aldosterone, and plasma angiotensin II (Ang II), creatinine clearance and urinary albumin excretion (UAE). In this small sample of hypertensive patients, losartan monotherapy and losartan-hydrochlorothiazide (HCTZ) combination therapy were associated with modest reductions in systolic, diastolic and mean arterial BPs; significant changes were observed only at the peak dosing interval. Losartan, given as either monotherapy or combination therapy, was associated with an increase in the 'trough' values of PRA; significant changes in the 'trough' values of plasma Ang II and plasma aldosterone were not observed. In contrast, PRA and plasma Ang II were stimulated, and plasma aldosterone was depressed, 6 h after dosing. There were significant negative correlations between both PRA and plasma Ang II reactivity (difference between PRA or plasma Ang II values obtained 6 h after placebo dosing and 6 h after drug dosing) and the change in systolic, diastolic and mean arterial BPs. Of interest, losartan/HCTZ combination therapy was associated with a decrease in the creatinine clearance; UAE was not significantly altered. Losartan appears to be an effective anti-hypertensive agent in patients with mild to moderate hypertension. Its peak BP effect appears to be at the dosing interval corresponding to pharmacological blockade of angiotensin II receptors. Furthermore, this anti-hypertensive agent may be more efficacious in patients with a reactive renin-angiotensin system.

Glomerular function and structure in the sodium-replete and sodium-deplete uninephrectomized spontaneously hypertensive rat: effect of blood pressure reduction, glomerular structure, and blood pressure reduction.

To assess the effects of chronic dietary sodium restriction and blood pressure reduction on glomerular function and structure during the pathogenesis of hypertensive renal disease, experiments were conducted in uninephrectomized (UNX) spontaneously hypertensive rats (SHR) using the dihydropyridine calcium antagonist manidipine. Male SHRs underwent UNX at age 10-11 weeks and subsequently were assigned to one of four groups: sodium-replete (0.4%); sodium-replete and a predetermined antihypertensive dose of manidipine (20 mg/kg body weight); sodium-deplete (0.09%); and sodium-deplete and manidipine (20 mg/kg body weight). Twelve weeks later, renal morphologic and functional studies were performed. Sodium restriction had no significant effect on systolic blood pressure, but creatinine clearance and urinary protein excretion were decreased. Importantly, mean glomerular volume and the prevalence of mesangial expansion were lower with sodium restriction. This occurred in the presence of high concentrations of plasma and renal tissue angiotensin II. Manidipine significantly reduced systolic blood pressure in the sodium-replete and sodium-deplete UNX-SHRs. This therapy was not associated with significant changes in creatinine clearance and urinary protein excretion in the sodium-deplete or sodium-replete UNX-SHRs. The prevalence of mesangial expansion in the sodium-replete UNX-SHR was approximately 50% lower with manidipine. Plasma and renal tissue angiotensin II concentrations were not affected by the drug. In the sodium-deplete UNX-SHR, the prevalence of mesangial expansion was not reduced further by manidipine. However, plasma and renal tissue angiotensin II concentrations were increased significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

Do calcium channel blockers have renal protective effects?

Calcium channel blockers are used in the treatment of hypertension because of their ability to decrease peripheral vascular resistance. Recent research has suggested that these drugs also preserve or improve renal function in patients with essential hypertensive renal disease or diabetic renal disease, and in renal transplant recipients with or without cyclosporin therapy. In general, studies in animal models of hypertension and in hypertensive humans have demonstrated reduction in renal vascular resistance, and preservation or enhancement of renal plasma flow and glomerular filtration rate. In addition, calcium channel blockers appear to have a positive effect on renal addition, calcium channel blockers appear to have a positive effect on renal haemodynamic function in the setting of diabetes mellitus; prospective trials have also demonstrated reductions in urinary protein excretion in these patients. Current evidence suggests that calcium channel blockers are well-suited for the treatment of patients with hypertensive disease even in the presence of renal impairment, a clinical scenario common in the elderly population.

Calcitonin gene-related peptide and the kidney.

Calcitonin gene-related peptide (CGRP) is a recently discovered neurotransmitter that is extensively localized in fibers innervating vascular and endocrine systems. CGRP possesses potent vasorelaxant effects, and a role for this peptide in the regional regulation of blood flow has been suggested. Although pharmacologic evidence indicates that the renal vasculature is very sensitive to CGRP, the physiologic actions of this peptide on the kidney have not yet been fully elucidated. This short review focuses on relevant experimental and clinical information of the direct and indirect effects of CGRP on renal function with an emphasis on hemodynamics, sodium excretion, and the renin-angiotensin system.

Urinary angiotensin II: a marker of renal tissue activity?

The methodology for the collection, extraction, separation and measurement of urinary angiotensin II [the octapeptide, ANG(1-8)] is described. To determine the origin of urinary ANG(1-8), mean arterial pressure, renal hemodynamics and the arterial, renal venous and urinary concentrations of ANG(1-8) were examined prior to and following the constant intra-arterial infusion of tritiated angiotensin II [3H-ANG(1-8)] in graded doses of 0.5, 2.0 and 2.5 ng/kg/min in 5 uninephrectomized, anesthetized female dogs. The infusion of 3H-ANG-(1-8) had no significant effect on mean arterial pressure, glomerular filtration rate, renal blood flow or urine flow rate. The mean concentration of ANG(1-8) in the urine was 3.7 fmol/ml. None or only trace amounts of 3H-ANG(1-8) were detected in the urine in spite of marked increases in renal arterial 3H-ANG(1-8) concentrations. These observations suggest that urinary ANG(1-8) was derived de novo from the intrarenal generation of angiotensin II. In addition, plasma and urinary concentrations of ANG(1-8) were assessed in patients with essential hypertension undergoing treatment with either a diuretic (n = 14) or an angiotensin-converting enzyme inhibitor (n = 14). Although the concentrations of plasma ANG(1-8) responded appropriately to the respective therapies, the urinary excretion of ANG(1-8) was not different following either therapy. These data suggest that ANG(1-8) collected from the urinary bladder may not occur in adequate concentrations to accurately assess the activity of the intrarenal renin-angiotensin system.

Renal tissue angiotensin II: response to infusions of angiotensin I and an angiotensin-converting enzyme inhibitor.

A procedure for the collection, processing, extraction, separation, and measurement of renal tissue angiotensin II [ANG-(1-8)] is described. The arterial plasma and renal tissue concentrations of ANG-(1-8) were examined in anesthetized Sprague-Dawley male rats (10 to 12 weeks of age) given an intravenous saline infusion (group 1; n = 6), an intravenous bolus infusion of 0.5 microgram angiotensin I (group 2; n = 6), or an intravenous bolus of an angiotensin-converting enzyme inhibitor (group 3; n = 6). Plasma and renal tissue were collected at the peak mean arterial pressure (MAP) response. The mean (+/- SEM) concentration of ANG-(1-8) in the group given the saline vehicle was 12 +/- 2 fmol/mL in the plasma and 2.4 +/- 0.3 pmol/g in the renal tissue. The angiotensin I bolus significantly increased MAP by 40%. Following the angiotensin I infusion, at the time of peak MAP response, the concentration of the circulating and renal tissue ANG-(1-8) were 12-fold and twofold higher, respectively, compared with the saline vehicle. The angiotensin-converting enzyme inhibitor significantly decreased MAP by 10% and decreased the circulating and renal tissue ANG-(1-8) levels by 75% and 62.5%, respectively, compared with the saline vehicle. The rapid conversion of exogenous angiotensin I to ANG-(1-8) in renal tissue provides direct evidence that renal tissue can generate de novo ANG-(1-8) from a circulating precursor. Furthermore, plasma and renal tissue respond similarly to acute angiotensin-converting enzyme inhibition.

Renin-angiotensin system and myocardial fibrosis in hypertension: regulation of the myocardial collagen matrix.

The cardiac interstitium is composed of non-myocyte cells embedded in a highly organized extracellular matrix containing a three-dimensional collagen network which serves to maintain the architecture of the myocardium and determines myocardial stiffness. In hypertensive heart disease, a heterogeneity in myocardial structure, created by the altered behaviour of cardiac fibroblasts responsible for collagen synthesis and degradation, can explain the appearance of diastolic and ultimately systolic dysfunction of the left ventricle. In vivo, circulating and myocardial renin-angiotensin systems (RAS) were found to be involved in the regulation of the structural remodelling of the cardiac interstitium. In vitro, in cultured adult rat cardiac fibroblasts, angiotensin II was shown to stimulate collagen synthesis and to inhibit collagenase activity, which is the key enzyme for collagen degradation. In the SHR-model of primary hypertension, left ventricular hypertrophy could be regressed and abnormal myocardial diastolic stiffness, due to interstitial fibrosis, could be restored to normal by inhibition of the myocardial RAS. These antifibrotic or cardioreparative effects of ACE inhibition that occurred irrespective of blood pressure normalization may be valuable in reversing left ventricular diastolic dysfunction in hypertensive heart disease.

Calcium channel blockers: do they offer renal protection?

Calcium channel blockers are used in the treatment of hypertension because of their ability to decrease peripheral vascular resistance. Recent research has suggested that these drugs also preserve or improve renal function in patients with essential hypertensive renal disease, diabetic renal disease, and in renal transplant recipients with or without cyclosporine therapy. In general, studies in both animal models and humans have demonstrated maintenance or reduction in renal vascular resistance, and preservation or enhancement of renal blood flow and glomerular filtration rate. In addition, calcium channel blockers appear to have a positive effect on renal haemodynamic function in the setting of diabetes mellitus; prospective trials have demonstrated reductions in urinary protein excretion in these patients. Current evidence suggests that calcium channel blockers are well suited for the treatment of patients with hypertensive disease even in the presence of renal impairment.

Short- and long-term effects of spirapril on renal hemodynamics in patients with essential hypertension.

Sixteen essential hypertensive patients were entered into a protocol assessing the effect of Spirapril, an angiotensin-converting enzyme (ACE) inhibitor, on blood pressure, the renin-aldosterone system, and renal function. Specifically monitored before, during 6 weeks, and 6 months of Spirapril therapy were plasma renin activity, plasma aldosterone, serum ACE, the renal clearances of creatinine, inulin, and para-aminohippurate, and urinary albumin excretion. Blood pressure was well controlled. Spirapril stimulated plasma renin activity and suppressed ACE throughout the entire protocol. Renal clearances were unchanged. Renal vascular resistance was decreased. Urinary albumin excretion was decreased. The authors conclude that the ACE inhibitor, Spirapril, when used as an effective antihypertensive agent, preserves renal function, lowers renal vascular resistance, and decreases urinary albumin excretion.