[Role of physical and rehabilitation medicine in the aftermath of SARS-CoV-2 disease]. / Rôle de la médecine physique et réadaptation fonctionnelle dans les suites d'une atteinte au SARS-CoV-2.

2020 will be remembered as the year of SARS-CoV-2 pandemic which confined most of the world's population at home. Rehabilitation units will have to face specific challenges to protect the vulnerable in-patients. Moreover, they must prepare for post-COVID-19 patients who might suffer from illness consequences or present a post intensive care syndrome secondary to the increased ICU length of stay. The purpose of this paper is to highlight the deficiencies of post-COVID-19 patients and suggest a decision algorithm to best match their needs.

L'année 2020 restera marquée par la pandémie de SARS-CoV-2, originaire de Chine, qui a confiné une grande partie de la population mondiale. Les services de médecine physique et rééducation fonctionnelle ont dû adopter des mesures spécifiques afin de limiter la contagion de leurs patients, appartenant à la population à risque. Ils se préparent également à l'accueil et à la prise en charge des patients post-COVID-19 présentant des séquelles secondaires à l'infection ou à l'hospitalisation prolongée en réanimation, responsable d'un syndrome post-soins intensifs. L'objectif de cet article est de dégager les différentes pathologies auxquelles les médecins rééducateurs seront confrontés et de proposer un algorithme décisionnel pour orienter la prise en charge rééducative.

Oat1/3 restoration protects against renal damage after ischemic AKI.

Expression of proximal tubular organic anion transporters Oat1 and Oat3 is reduced by PGE2 after renal ischemia and reperfusion (I/R) injury. We hypothesized that impaired expression of Oat1/3 is decisively involved in the deterioration of renal function after I/R injury. Therefore, we administered probenecid, which blocks proximal tubular indomethacin uptake, to abolish the indomethacin-mediated restoration of Oat1/3 regulation and its effect on renal functional and morphological outcome. Ischemic acute kidney injury (iAKI) was induced in rats by bilateral clamping of renal arteries for 45 min with 24-h follow-up. Low-dose indomethacin (1 mg/kg) was given intraperitoneally (ip) at the end of ischemia. Probenecid (50 mg/kg) was administered ip 20 min later. Indomethacin restored the expression of Oat1/3, PAH net secretion, and PGE2 clearance. Additionally, indomethacin improved kidney function as measured by glomerular filtration rate (GFR), renal perfusion as determined by corrected PAH clearance, and morphology, whereas it reduced renal cortical apoptosis and nitric oxide production. Notably, indomethacin did not affect inflammation parameters in the kidneys (e.g., monocyte chemoattractant protein-1, ED1+ cells). On the other hand, probenecid blocked the indomethacin-induced restoration of Oat1/3 and moreover abrogated all beneficial effects. Our study indicates that the beneficial effect of low-dose indomethacin in iAKI is not due to its anti-inflammatory potency, but in contrast to its restoration of Oat1/3 expression and/or general renal function. Inhibition of proximal tubular indomethacin uptake abrogates the beneficial effect of indomethacin by resetting the PGE2-mediated Oat1/3 impairment, thus reestablishing renal damage. This provides evidence for a mechanistic effect of Oat1/3 in a new model of the induction of renal damage after iAKI.

NF-κB-mediated inverse regulation of fractalkine and CX3CR1 during CLP-induced sepsis.

Fractalkine is a unique member of the CX3C chemokine family by unfolding its potential through the chemokine (C-X3-C motif) receptor 1 (CX3CR1) with dual function acting both as an adhesion molecule and a soluble chemokine. The regulation of this chemokine is still not clear. Therefore, we were interested in the regulation of fractalkine and of CX3CR1 in experimental sepsis. In addition, we investigated the role of NF-κB for the regulation of fractalkine and of CX3CR1. Using a mouse model of cecal ligation and puncture (CLP)-induced sepsis, we found elevated fractalkine mRNA levels in the heart, lung, kidney, and liver, as well as increased plasma levels 24 and 48h after CLP, respectively. In parallel, CLP resulted in a significant downregulation of CX3CR1 mRNA receptor expression in all investigated murine tissues. Septic mice that were pretreated with the selective NF-κB inhibitor pyrrolidine dithiocarbamate (PDTC) were found to have a decreased liberation of proinflammtory cytokines such as TNF-α, IL-1ß, IL-6, or IFN-γ. Further PDTC pretreatment attenuated CLP-induced downregulation of CX3CR1 mRNA as well as CLP-induced upregulation of fractalkine mRNA expression in the heart, lung, kidney, liver, and the increase in fractalkine plasma levels of septic mice. In addition, CLP-induced downregulation of renal CX3CR1 protein expression was inhibited by PDTC-pretreatment. Taken together, our data indicate a CLP-induced inverse regulation of the expression between the relating ligand and the receptor with an upregulation of fractalkine and downregulation of CX3CR1, which seems to be mediated by the transcripting factor NF-κB likely via reduced liberation of proinflammtory cytokines in the whole murine organism.

Nitric oxide-induced regulation of renal organic cation transport after renal ischemia-reperfusion injury.

Renal organic cation transporters are downregulated by nitric oxide (NO) in rat endotoxemia. NO generated by inducible NO synthase (iNOS) is substantially increased in the renal cortex after renal ischemia-reperfusion (I/R) injury. Therefore, we investigated the effects of iNOS-specific NO inhibition on the expression of the organic cation transporters rOct1 and rOct2 (Slc22a1 and Slc22a2, respectively) after I/R injury both in vivo and in vitro. In vivo, N(6)-(1-iminoethyl)-L-lysine (L-NIL) completely inhibited NO generation after I/R injury. Moreover, L-NIL abolished the ischemia-induced downregulation of rOct1 and rOct2 as determined by qPCR and Western blotting. Functional evidence was obtained by measuring the fractional excretion (FE) of the endogenous organic cation serotonin. Concordant with the expression of the rate-limiting organic cation transporter, the FE of serotonin decreased after I/R injury and was totally abolished by L-NIL. In vitro, ischemia downregulated both rOct1 and rOct2, which were also abolished by L-NIL; the same was true for the uptake of the organic cation MPP. We showed that renal I/R injury downregulates rOct1 and rOct2, which is most probably mediated via NO. In principle, this may be an autocrine effect of proximal tubular epithelial cells. We conclude that rOct1, or rOct1 and rOct2 limit the rate of the renal excretion of serotonin.

Indomethacin corrects alterations associated with ischemia/reperfusion in an in vitro proximal tubular model.

BACKGROUND/AIMS: Recent in vivo data indicate that indomethacin improves renal outcome after ischemia via improvement of renal cell survival and function. To examine direct effects of indomethacin on isolated proximal tubular cells, we investigated the influence of indomethacin on markers of ischemia/reperfusion (I/R) damage in an established in vitro model of ischemia and reperfusion. METHODS: Ischemia was applied for 2 h followed by reperfusion for up to 48 h. Indomethacin was added at the beginning of reperfusion. Parameters were investigated after 6, 24 or 48 h of reperfusion. RESULTS: Indomethacin diminished cell death by necrosis and apoptosis, release of prostaglandin E2, induction of I/R-induced protein, dedifferentiation or induction of inducible nitric oxide synthase. Moreover, indomethacin totally prevented the ischemia-induced inhibition of basolateral organic anion transport. Indomethacin did not affect ischemia-mediated induction of nuclear factor-kappaB or monocyte chemoattractant protein 1. Ischemia did not induce matrix protein synthesis. CONCLUSIONS: We have shown that: (a) indomethacin applied after ischemia has a beneficial effect on proximal tubule cell survival after model ischemia and impairs changes of parameters characteristically induced by ischemia via direct action on proximal tubule cells; (b) the inflammatory response of proximal tubule cells was not affected by indomethacin, and (c) fibrosis does not take place after model ischemia in isolated proximal tubule cells.

Low-dose indomethacin after ischemic acute kidney injury prevents downregulation of Oat1/3 and improves renal outcome.

We have previously shown that expression of renal organic anion transporters Oat1 and Oat3 is diminished by prostaglandin E(2) (PGE(2)) and that both transporters are downregulated after renal ischemia. Because PGE(2) is increased after renal ischemia and is generated by cyclooxygenases (COX), we investigated the effect of the COX inhibitor indomethacin on expression of Oat1/3 after ischemic acute kidney injury (iAKI). iAKI was induced in rats by bilateral clamping of renal arteries for 45 min. Indomethacin (1 mg/kg) was given intraperitoneally as soon as reperfusion started. Sham-treated animals served as controls. Oat1/3 were determined by qPCR and Western blot. PGE(2) in blood and urine was measured by enzyme-linked immunosorbent assay. Invasion of monocytes/macrophages was determined. Glomerular filtration rate and renal plasma flow were determined. All parameters were detected 24 h after ischemia. PAH net secretion, as well as clearance and secretion of PGE(2) were calculated. In clamped animals, indomethacin restored expression of Oat1/3, as well as PAH net secretion, PGE(2) clearance, or PGE(2) secretion. Additionally, indomethacin substantially improved kidney function as measured by glomerular filtration and PAH clearance. Indomethacin did not affect ischemia-induced invasion of monocytes/macrophages. In conclusion, our study indicates that low-dose indomethacin applied after ischemia prevents ischemia-induced downregulation of Oat1/3 during reperfusion and has a substantial protective effect on kidney function after iAKI. The beneficial effect of low-dose indomethacin on renal outcome is likely due to an effect different from inhibition of inflammation. In accordance to the decreased PAH net secretion, renal excretion of an endogenous organic anion (PGE(2)) is also impaired after ischemia and reperfusion.

Direct determination of intracellular daunorubicin in intact confluent monolayers of AT1 prostate carcinoma cells using a multiwell-multilabel counter.

The cytostatic drug daunorubicin exerts its toxic action by intercalating into the DNA. The efficacy of daunorubicin depends on the intracellular amount in the tumor cell. Here we have evaluated the use of a multiwell-multilabel reader for the direct determination of the fluorescent cytostatic drug daunorubicin in a prostate carcinoma cell line (AT1 R-3327 Dunning prostate carcinoma cells) grown on 24-well plates. We present evidence that this simple fluorescent parameter is a good measure for the toxicologically relevant amount of the drug intercalated into the DNA and, therefore, is a good predictor for the drug's cytotoxicity. The amount of cationic cytostatics in a tumor cell is primarily a function of the efflux pump protein p-gycoprotein (pGP). Therefore, it is of great value that the assay is also suitable for the estimation of the multidrug resistance efflux pump (pGP) activity.

Downregulation of organic anion transporters OAT1 and OAT3 correlates with impaired secretion of para-aminohippurate after ischemic acute renal failure in rats.

Ischemic acute renal failure (iARF) was described to reduce renal extraction of the organic anion para-aminohippurate (PAH) in humans. The rate-limiting step of renal organic anion secretion is its basolateral uptake into proximal tubular cells. This process is mediated by the organic anion transporters OAT1 and OAT3, which both have a broad spectrum of substrates including a variety of pharmaceutics and toxins. Using a rat model of iARF, we investigated whether impairing the secretion of the organic anion PAH might be associated with downregulation of OAT1 or OAT3. Inulin and PAH clearance was determined starting from 6 up to 336 h after ischemia-reperfusion (I/R) injury. Net secretion of PAH was calculated and OAT1 as well as OAT3 expression was analyzed by RT-PCR and Western blotting. Inulin and PAH clearance along with PAH net secretion were initially diminished after I/R injury with a gradual recovery during follow-up. This initial impairment after iARF was accompanied by decreased mRNA and protein levels of OAT1 and OAT3 in clamped animals compared with sham-operated controls. In correlation to the improvement of kidney function, both mRNA and protein levels of OAT1 and OAT3 were upregulated during the follow-up. Thus decreased expression of OAT1 and OAT3 is sufficient to explain the decline of PAH secretion after iARF. As a result, this may have substantial impact on excretion kinetics and half-life of organic anions. As a consequence, the biological effects of a variety of organic anions may be affected after iARF.

Proximal tubular toxicity of ochratoxin A is amplified by simultaneous inhibition of the extracellular signal-regulated kinases 1/2.

Ochratoxin A (OTA) is a mycotoxin involved in the development of chronic nephropathies and a known carcinogen. As we have shown previously, OTA activates mitogen-activated protein kinases [extracellular signal-regulated kinase 1 and 2 (ERK1/2), c-jun amino-terminal kinase (JNK), and extracellular-regulated protein kinase 38 (p38)] in proximal tubular cells (opossum kidney and normal rat kidney epithelial). ERK1/2, JNK, or p38 are thought to mediate opposite action on apoptosis, fibrosis, and inflammation. As we have already shown, OTA activates the latter processes. Here, we investigated the effect of OTA in the absence or presence of the ERK1/2 inhibitor U0126 [1,4-diamino-2,3-dicyano-1,4bis(2-aminophenylthio)-butadiene] to test whether OTA then will exert increased toxicity. In the presence of ERK1/2 inhibition, OTA decreased cell number and protein to a significantly larger extent compared with OTA alone. The same was true for epithelial tightness, apoptosis (caspase-3 activity), and necrosis (lactate dehydrogenase release). Furthermore, simultaneous inhibition of ERK1/2 amplified the effect of OTA on markers of inflammation (nuclear factor of the kappa-enhancer in B cells activity), fibrosis (collagen secretion), and epithelial mesenchymal transition (alpha smooth muscle actin). OTA induces phenomena typical for chronic interstitial nephropathy and activates ERK1/2, JNK, and p38 in proximal tubular cells. Inhibition of ERK1/2 aggravates the effects of OTA or even induces toxicity at normally nontoxic concentrations. This is highly likely due to activation of JNK and p38. Our data indicate a new mechanistic explanation for the toxic actions induced by OTA, and they are notable with respect to a possible coexposition of the kidney to OTA and naturally occurring ERK1/2 inhibitors. Finally, our data give rise to an attractive hypothesis on the coincidence of increased OTA exposition and urinary tract tumors in humans.

Action of EGF and PGE2 on basolateral organic anion uptake in rabbit proximal renal tubules and hOAT1 expressed in human kidney epithelial cells.

We recently showed that, in a proximal tubule cell line (opossum kidney cells), epithelial growth factor (EGF) stimulates basolateral organic anion transport (OAT) via ERK1/2, arachidonic acid, phospholipase A2, and generation of prostaglandins. PGE2 binds the prostanoid receptor and, thus, activates adenylate cyclase and PKA, which stimulate basolateral organic anion uptake. In the present study, we investigated whether this regulatory cascade is also true 1) for ex vivo conditions in isolated renal proximal (S2) tubules from rabbit and 2) in a human renal epithelial cell line stably expressing human OAT1 (IHKE-hOAT1). EGF activated ERK1/2 in S2 tubules and IHKE-hOAT1, and, in both cases, inhibition of ERK activation (by U-0126) abolished this stimulation. In S2 tubules and IHKE-hOAT1, EGF led to an increase of organic anion uptake, which again was inhibited by U-0126. PGE2 stimulated basolateral organic anion uptake in rabbit S2 tubules and IHKE-hOAT1. EGF- and PGE2-mediated stimulation of organic anion uptake was abolished by inhibition of PKA in rabbit S2 tubules and IHKE-hOAT1, respectively. We conclude that 1) stimulation of basolateral organic anion uptake by EGF or PGE2 is a widespread (if not general) regulatory mechanism, 2) the signal transduction pathway involved seems to be general, 3) stimulation of basolateral organic anion uptake by EGF or PGE2 is also present under ex vivo conditions and, thus, is not a cell culture artifact, 4) activation of OAT1 is sufficient to explain the stimulatory effects of EGF and PGE2 in opossum kidney cells and rabbit S2 segments, and 5) stimulation of basolateral OAT1 by EGF or PGE2 is also important in humans and, thus, may have clinical implications.

Inhibition of the mitogen activated protein kinase ERK1/2 amplifies ochratoxin A toxicity in the proximal tubule of the kidney.

Ochratoxin A (OTA) is a mycotoxin showing nephrotoxic properties. OTA activates the mitogen activated protein kinases ERK, JNK and p38 in renal epithelial cells. In brief, activation of ERK supports mitosis, growth and differentiation, whereas JNK and p38 are considered to induce the opposite effects. The balance of the mentioned key protein kinases decides the further fate of the cell. In renal disease, the proximal tubule of the nephron often is affected first.Thus, we investigated the effect of OTA incubation (24 or 48 hours) on proximal tubular OK cells (oppossum) and/or NRK-52E cells (rat) in presence of an inhibitor of ERK1/2 activation (U0126). U0126 (25 µM) completely abolished ERK1/2 activation induced by OTA. Parameters indicating necrosis, apoptosis, epithelial tightness, fibrosis, dedifferentiation and inflammation were determined. In presence of U0126, OTA led to a decrease of cell number as compared to OTA alone. U0126 in presence of OTA increased LDH release as compared to OTA alone. OTA alone did not change epithelial integrity, whereas OTA in presence of U0126 reduced epithelial tightness. 100 nM OTA alone did not increase apoptosis, while addition of U0126 to OTA induced apoptotis. U0126 stimulated the basolateral deposition of collagen induced by OTA. Furthermore, as investigated by RT-PCR, the effect of OTA on markers of inflammation (NF-κB) and dedifferentiation (α-smooth muscle actin) was also more pronounced when ERK1/2 was inhibited. ERK1/2 inhibition enhanced the effects of OTA. Thus, activation of ERK1/2 after OTA is a protective mechanism. We conclude that ERK1/2 not only acts anti-apoptotic but also is beneficial on cell viability, epithelial tightness, interstitial fibrosis, inflammation and trans-differentiation. We further conclude that ERK1/2 is a key protection factor in the proximal tubule. However, long term OTA exposition could lead to clonal selection of kidney cells overexpressing ERK1/2. As strong expression of ERK1/2 is found in various tumours not only of the kidney, we hypothesize that the mentioned clonal selection could be a mechanism inducing the cancerogenic action discussed for OTA.

Determination of basolateral Na(+)/H(+) exchange activity in MDCK cells using a multiwell-multilabel reader.

Na(+)/H(+) exchangers (NHE) are important membrane transport proteins involved in transepithelial transport and cellular pH homeostasis. NHE-1, important for cellular pH and volume homeostasis, is expressed in the basolateral membrane of epithelial cells. We evaluated the use of a multiwell-multilabel reader to investigate basolateral NHE-1 in confluent MDCK cells and compared the results with data obtained using an imaging system equipped with a filter perfusion system. Using the multiwell-multilabel reader we obtained virtually the same values for steady-state pH and NHE-1 activity under control conditions compared to the imaging system. With both setups Na(+)-dependent pH recovery after an acid load occurred virtually only after basolateral addition of Na(+). Furthermore, Na(+)-dependent pH recovery was reduced by >80% in the presence of the NHE-1 inhibitor HOE642. In addition, we detected an almost identical increase of NHE-1 activity with the two methods after stimulation of protein kinase C using phorbol myristate acetate. In summary, our data indicate that multiwell-multilabel readers are suitable to investigate physiology and regulation of basolateral NHE. Thus, multiwell-multilabel readers offer a valid and convenient alternative to investigate basolateral transporters.

Modulation of the basolateral and apical step of transepithelial organic anion secretion in proximal tubular opossum kidney cells. Acute effects of epidermal growth factor and mitogen-activated protein kinase.

The organic anion transport system in the proximal tubule of the kidney is of major importance for the excretion of a variety of endogenous and potentially toxic exogenous substances. Furthermore, the clearance of model substrates (e.g. para-aminohippurate) of this system is used for the determination of renal blood flow. We investigated regulation of organic anion secretion in a way that allowed us to examine simultaneously regulation of overall transepithelial secretion and to estimate the separate contributions of regulation of the basolateral and apical transport steps to this overall regulation. The data were verified by measurement of initial basolateral uptake rate and initial apical efflux rate. Opossum kidney cells were used as a suitable model system for proximal tubule cells, and [14C]para-aminohippurate was utilized as an organic anion. Stimulation of protein kinase C inhibited transepithelial secretion because of inhibition of both apical efflux and basolateral uptake. Inhibition of the mitogen-activated protein kinase (MAPK) kinase MEK reduced transepithelial secretion via inhibition of basolateral uptake and apical efflux. Epidermal growth factor (EGF) enhanced transepithelial secretion via stimulation of basolateral uptake but did not affect apical efflux. EGF induced stimulation of basolateral uptake was abolished by inhibition of MEK. EGF led to phosphorylation of ERK1/2, which was also abolished by inhibition of MEK. Thus, EGF stimulated basolateral uptake of organic anions via MAPKs. Transepithelial organic anion secretion can be regulated at two sites, at least: basolateral uptake and apical efflux. Both steps are under control of protein kinase C and MAPK. The pathophysiologically relevant growth factor EGF enhances transepithelial secretion via stimulation of basolateral uptake. EGF stimulates basolateral uptake via MEK and ERK1/2. Thus, renal organic anion extraction may be modulated, especially under pathophysiological conditions.

Inhibition of initial transport rate of basolateral organic anion carrier in renal PT by BK and phenylephrine.

The effect of ligands for phospholipase C-coupled receptors and of protein kinase C (PKC) stimulation with phorbol ester [phorbol 12-myristate 13-acetate (PMA)] or 1,2-dioctanoyl-sn-glycerol on the activity of the basolateral organic anion transporter (OAT) in S2 segments of single, nonperfused rabbit proximal tubules (PT) was measured with the use of fluorescein and epifluorescence microscopy. The initial uptake rate (25 s, OAT activity) was measured in real time by using conditions similar to those found in vivo. Stimulation of PKC with PMA or 1,2-dioctanoyl-sn-glycerol led to an inhibition of OAT activity, which could be prevented by 10(-7) mol/l of the PKC-specific inhibitor bisindolylmaleimide. The alpha(1)-receptor agonist phenylephrine as well as the peptide hormone bradykinin induced a reversible decrease of OAT activity, which was prevented by bisindolylmaleimide. The observed effect was not due to a decrease in the concentration of the counterion alpha-ketoglutarate or to impaired alpha-ketoglutarate recycling, because it was unchanged in the continuous presence of alpha-ketoglutarate or methyl succinate. We conclude that physiological stimuli can inhibit the activity of OAT in rabbit PT via PKC. The effect is not mediated by alterations in counterion availability but by a direct action on the OAT.

Exposure to ochratoxin A impairs organic anion transport in proximal-tubule-derived opossum kidney cells.

Ochratoxin A (OTA) is a widespread mycotoxin, which is nephrotoxic and carcinogenic. Because a decline in net-secretion of para-aminohippuric acid (PAH) was observed after chronic OTA exposition in vivo, we investigated the effect of OTA on proximal-tubule-derived opossum kidney (OK) cells. OTA up to 10(-5) mol/liter had no acute effect on PAH transport when bovine serum albumin (BSA) was present. By contrast, 72-hr incubation of OK cells led to a decrease of PAH transport with half-maximal inhibition at 6 . 10(-7) mol/liter for transepithelial secretion and 6 . 10(-8) mol/liter for basolateral uptake of PAH. Incubation of OK cells with 10(-6) mol/liter OTA for 72 hr reduced the affinity of PAH uptake, and decreased the maximum secretion rate to one-fifth of control values. Apical uptake of amino acids and basolateral uptake of glutarate were not affected. In addition, no signs of general toxic action could be observed. Specific basolateral binding affinity of PAH was reduced to 50% of control. Furthermore, incubation with OTA led to a decrease of PAH efflux across the apical membrane, although efflux across the basolateral membrane and the amount remaining in the cells increased as compared to control. By contrast to control cells, uptake of PAH in OTA-treated cells was not stimulated after preloading with glutarate. Our data show, that 1) long-term incubation with free OTA in the nanomolar range reduces the activity of the organic anion transporter, 2) without influencing general cell function. 3) OTA seems to act preferentially on organic anion transport, by affecting the exchange of organic anions and dicarboxylates. 4) Thereby, OTA reduces its own secretion. 5) The excretion of other xenobiotics and drugs may be also impaired, whereby OTA can exert an indirect toxic action.