Lise BANKIR. Paris, France WATER

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1 Lise BANKIR INSERM Unit 872, Centre de Recherche des Cordeliers Paris, France WATER

2 Nadine BOUBY Pascale BARDOUX Julie PERUCCA INSERM Unit 872, Paris Daniel BICHET University of Montreal, Canada Miche MARRE Dept of Endocrinology, Paris Several other MDs in Hypertension, Endocrinology, and Metabolism

3 Outline 1. Introduction about vasopressin (VP) and its receptors 2. Vasopressin effects through V2 receptors v Sodium excretion (hypertension) v Glom. filtration rate (chronic kidney disease) v Albumin excretion (diabetic nephropathy) 3. Interpretation and consequences

4 The mammalian kidney is well adapted to produce hyperosmotic urine Specialized vascular beds in different cortical and medullary regions Gradient of solutes in the medulla. Collecting ducts traverse the whole kidney, allowing urine concentration in the medulla under the influence of vasopressin

5 Vasopressin = AVP or Antidiuretic hormone = ADH ü Allows urine to be concentrated above plasma osmolality (AVP is indispensable for this function, but AVP is not sufficient: many other conditions are also required) Lack of AVP or unresponsiveness of the kidney to AVP >>> diabetes insipidus ü ü ü ü Small peptidic hormone (9 amino acids), secreted by the neurohypophysis Very old hormone in evolution (worms, hydra, mollusc, insects) Released under the influence of two different stimuli ä plasma osmolality (mainly Na) or æ blood volume Very short half life (3-5 min) >>> Very fast effects & quickly reversible ( aldosterone)

6 AVP receptors : The classical view V2 (camp) V1a (Ca ++ ) Renal Collecting Duct Vasc. smooth muscle cells AQP2: Þ Permeability to water Vasoconstriction Þ Water Conservation Þ Blood pressure V1b (Ca ++ ) Expressed in multiples organs. In vivo effects poorly known

7 Sites of AVP receptor expression V2R (camp) V1aR (Ca ++ ) Kidney Blood vessels & blood Liver Lung Coll. Duct (basolateral) Coll. Duct (primary cilium) Thick ascending limb Endothelium (NO) Type II pneumocytes Glomeruli & Macula Densa Coll. Duct (luminal) Inters11al cells of the medulla Smooth muscle cells Platelets Hepatocytes Brain Other organs Inner ear, Eye (?) Certain brain nuclei Adrenal glands V1bR : Alpha and Beta cells of pancrea1c islets, Adrenals, Kidney Coll. Duct, Spleen, Uterus, Breast, Thymus, Heart

8 Renewed interest in Vasopressin in recent years In contrast to the renin-angiotensin-aldosterone system Vasopressin has been poorly studied for a long time (except for its acute effects on responsive tissues) WHY? ü Very low concentration (from undetectable to 3 pg/ml (10-12 M) ü Difficult to measure. Lower limit of immuno-assays = 0.5 pg/ml --->>> Now, COPEPTIN, a surrogate marker of vasopressin ü No good antagonists until recently ---->>> Now: the VAPTANS ü Not much attention paid by physicians to urine volume ü Urine osmolality rarely measured routinely

9 Main urinary solutes in plasma and urine of healthy subjects Urine/Plasma x 2.1 x 45 x 300 x 12 x 0.8 Most of the concentrating effort of the kidney is devoted to the concentration of UREA (the major end product of protein metabolism)

10 Three different actions of vasopressin on the collecting duct through V2 receptors Vasopressin does not act only on water permeability (AQP2). It also stimulates the membrane sodium channel ENaC and Urea transporters (UT-A1/3). This reduces the efficiency of sodium and urea excretion

11 Outline 1. Introduction about vasopressin (VP) and its receptors 2. Vasopressin effects through V2 receptors v Sodium excretion (hypertension) v Glom. filtration rate (chronic kidney disease) v Albumin excretion (diabetic nephropathy) 3. Interpretation and consequences

12 Hydration influences sodium but not potassium excretion rate after the hypertonic NaCl load Same healthy subjects studied twice at two weeks interval They received a hypertonic NaCl load via i.v. infusion Low hydration 15 ml every 30 min High hydration 140 ml every 30 min Choukroun et al, Am. J. Physiol Change in excretion rate, mmol/h This sodium-retaining effect is due to ENaC (blocked by amiloride) Blanchard et al, CJASN 2011

13 Relationship between Pulse Pressure and urine concentration in normotensive young men Pulse pressure, mm Hg r = 0.356, p < Index of urine concentration (U/P Creatinine) AA C ü 86 men, age y ü Same slope in African- American (AA) and Caucasiens (C), but higher pressure in AAs ü Positive correlation between PP and urine concentration (also with SPB, but not with DBP) ü In women: NS (but urine concentration is lower) Bankir and Weinberger CJASN. 2007

14 Hypertension in a large number of different populations : Genetic associations ü In 53 populations (Centre d Etude du Polymorphisme Humain, Fondation Jean Dausset), study of 7 functional polymorphisms in 5 genes participating in blood pressure control (including γ-enac). These polymorphisms are associated with latitude and climate. In other words, associated with heat adaptation (evaluated through a thermic stress index). ü Latitude also explains 47 % of the BP variation in the 35 populations of the INTERSALT study for which genetic data is available. Young & Chakravarti, PloS Genetics, 2005 Heat >> risk of dehydration >> increased AVP

15 Outline 1. Introduction about vasopressin (VP) and its receptors 2. Vasopressin effects through V2 receptors v Sodium excretion (hypertension) v Glom. filtration rate (chronic kidney disease) v Albumin excretion (diabetic nephropathy) 3. Interpretation and consequences

16 Increased GFR with increasing urine concentration Healthy rats, studied after one week on High Water intake or ddavp infusion Inulin clearance based on 24h urine N = 12 healthy subjects, acute study High Hydration = 4.0 ml/kg BW/30 min Low Hydration = 0.5 ml/kg BW/30 min Two weeks apart (random order) Inulin clearance (ml/min) High Water Intake Control ddavp infusion r = Urine osmolality (mosm/kg H20) Inulin clearance (ml/min) High Hydration Low Bouby et al, JASN, 1996 Anastasio et al, Kidney Int. 2001

17 Vicious circle due to hyperfiltration High protein diet or diabetes mellitus Glomerular hyperfiltration Adapted from Brenner, AJP 1985 Increased energy demand for reabsorption of extra solutes filtered Increased glomerular pressures and flows Reduced functionning nephron number Glomerular sclerosis Increased oxydative stress and interstitial inflammation Primary renal disease

18 High protein diet or diabetes mellitus Vicious circle due to hyperfiltration Increased glomerular pressures and flows Glomerular hyperfiltration Reduced functionning nephron number Adapted from Brenner, AJP 1985 Glomerular sclerosis Does AVP play a role in the Increased energy demand for reabsorption of extra solutes filtered progression of chronic kidney disease? Increased oxydative stress and interstitial inflammation Primary renal disease

19 In a rat model of chronic kidney disease, an increased water intake protects the kidney A 3-fold increase in water intake ameliorates proteinuria, blood pressure and glomerulosclerosis in rats with 5/6th nephrectomy (a classical model of progressive renal disease) Bouby & Bankir, Am.J.Physiol., 1990

20 Outline 1. Introduction about vasopressin (VP) and its receptors 2. Vasopressin effects through V2 receptors v Sodium excretion (hypertension) v Glom. filtration rate (chronic kidney disease) v Albumin excretion (diabetic nephropathy) 3. Interpretation and consequences

21 Diabetes mellitus v AVP is known to be elevated in diabetes mellitus. v About 1/3 of diabetic subjects develop diabetic nephropathy after several years of diabetes. Does AVP contribute to diabetic nephropathy? v A rise in urinary albumin excretion in diabetes mellitus is an early sign or renal dysfunction. v We showed that a chronic ddavp infusion in rats (one week) increases urinary albumin excretion 3-fold (reversible upon cessation of infusion)

22 ddavp infusion increases urinary albumin excretion in healthy subjects (n = 6) UAE (µg/ min) 30 * β 2 -microglob. (µg / min) ddavp min 20 min 0 * * * * * Creat excr. (mg / min) min Time This rise in UAE is NOT seen in subjects with diabetes insipidus due to mutations of the V2 receptor but it is observed in subjects with DI due to mutation of AQP2 Thus, it results from AVP action on V2 receptors Bardoux et al, NDT 18:497, 2003

23 In rats with type 1 diabetes mellitus a V2R antagonist protects the kidney V2R antagonist given orally at doses reducing urine concentration to an osmolality close to that in plasma Urine Osmolality Urine Flow rate mosm / kg H 2 O ml / d Anti-V *** *** *** *** 2 *** *** *** *** *** Cont *** weeks Anti-V 2 Cont Urinary albumin excretion (mg / d) ** ** weeks # # # Bardoux et al, NDT 18:1755, 2003 Cont Anti-V 2

24 Albuminuria in the 13 control (non treated) rats with type 1 diabetes mellitus (streptozotocin) Even without treatment, only about half of the rats with DM developed albuminuria. As in humans, there are individual differences in the susceptibility to develop nephropathy in rats. à Role of urine concentration? Urinary albumin excretion (mg/d) Progressors Non-progressors Urinary albumin excretion (mg/d) Week Week -1 Week + 9 Bardoux et al, NDT 18:1755, 2003

25 Outline 1. Introduction about vasopressin (VP) and its receptors 2. Vasopressin effects through V2 receptors v Sodium excretion (hypertension) v Glom. filtration rate (chronic kidney disease) v Albumin excretion (diabetic nephropathy) 3. Interpretation and consequences

26 Vicious circle due to hyperfiltration High protein diet or diabetes mellitus AVP Glomerular hyperfiltration Adapted from Brenner, AJP 1985 Increased energy demand for reabsorption of extra solutes filtered Increased glomerular pressures and flows Reduced functionning nephron number Glomerular sclerosis Increased oxydative stress and interstitial inflammation Primary renal disease

27 Summary of adverse effects of vasopressin v v v v Vasopressin increases GFR and urine albumin excretion in rats and healthy humans. Vasopressin contributes to progression of CKD and to the albuminuria of diabetic nephropathy in rats. Increased water intake or chronic treatment with a V2 antagonist is beneficial in animal models of CKD or diabetes mellitus Inter-individual differences in the susceptibility to diabetic nephropathy in rats are related to the intensity of urine concentrating activity These studies in rats demonstrate the contribution of vasopressin to the deterioration of kidney function through its effects on V2 receptors

28 Inter-individual and Sex differences in urine concentration Urine osmolality Plasma copeptin concentration p < p < Perucca et al, Am.J.Physiol Bhandari et al, Clin.Science, 2009 This sex difference may explain the greater susceptibility of males to nephrolithiasis, hypertension, more rapide progression of CKD, etc...

29 Water conservation and efficient solute excretion Normal interplay between two opposite needs Increase in sodium and urea reabsorption that allows better water conservation Less efficient excretion of sodium and urea. Increase in GFR and blood pressure that counteracts the effects of AVP on salt and urea excretion Immediate water economy Long term adverse effects

30 Our ancestral heritage In prehistorical times, the need to conserve water was a strong PRIORITY. Severe lack of water is lethal in a few days. Life expectancy was short. The delayed consequences of high urine concentration did not have time to appear. In present times, the need to conserve water has decreased because water is easily available (in Western countries) >>>>> But the mechanisms (and the structure of the kidney) allowing water conservation have remained powerful. The water conservation mechanism operates at the expense of a less efficient excretion of several solutes. This has to be compensated in ways that aggravate all other problems the kidney may have to face.

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