Search

Febuxostat is a nonpurine xanthine oxidase (XO) inhibitor, which recently received marketing approval. However, information regarding the experience with this agent among advanced chronic kidney disease (CKD) patients is limited. In the current study, we investigated the effects of oral febuxostat in patients with advanced CKD with asymptomatic hyperuricemia. We demonstrated, for the first time, that not only the serum levels of uric acid (UA) but also those of 8-hydroxydeoxyguanosine, an oxidative stress marker, were significantly reduced after six months of febuxostat treatment, with no adverse events. These results encouraged us to pursue further investigations regarding the clinical impact of lowering the serum UA levels with febuxostat in advanced CKD patients in terms of concomitantly reducing oxidative stress via the blockade of XO. More detailed studies with a larger number of subjects and assessments of the effects of multiple factors affecting hyperuricemia, such as age, sex, and dietary habits, would shed light on the therapeutic challenges of treating asymptomatic hyperuricemia in patients with various stages of CKD.

Objective: The long-term effects of aliskiren in hypertensive hemodialysis patients remain to be elucidated., Design: In this post hoc analysis, we followed up 25 hypertensive hemodialysis patients who completed 8-week aliskiren treatment in a previous study for 20 months to investigate the blood pressure-lowering effect and inhibitory effect on the renin-angiotensin-aldosterone system., Results: Among the 25 patients, eleven patients continued with aliskiren treatment. Blood pressure (± standard deviation) decreased from 175 ± 18/80 ± 11 mmHg at baseline to 156 ± 20/76 ± 9 mmHg at month 20. Plasma renin activity, angiotensin I, and angiotensin II decreased from baseline to month 20 (plasma renin activity (ng/mL/h): 2.3 ± 2.6 to 0.3 ± 0.4 (P < 0.05), angiotensin I (pg/mL): 909.1 ± 902.5 to 41.5 ± 14.8 (P < 0.05), angiotensin II (pg/mL): 41.5 ± 45.8 to 11.0 ± 4.9 (P < 0.05))., Conclusion: Long-term treatment with aliskiren provides effective blood pressure lowering and inhibition of the renin-angiotensin-aldosterone system, which are sustained over 20 months in hypertensive hemodialysis patients.

Background: Circulating prorenin contributes to the pathogenesis of tissue damage leading to cardiovascular disease (CVD) in hypertension and diabetic mellitus (DM) by activating the tissue renin-angiotensin-aldosterone (RAS) system; however, little is known about its roles in hemodialysis (HD) patients., Methods: We evaluated plasma prorenin level and prorenin receptor [(P)RR] expression in peripheral blood mononuclear cells (PBMCs) in 49 nondiabetic HD (non-DM-HD) patients. Then we investigated the association between plasma prorenin level or (P)RR expression level in PBMCs and CVD-predictive biomarkers., Results: The plasma prorenin level increased in non-DM-HD patients [147.1 ± 118.9 pg/ml (standard value <100 pg/ml)]. The (P)RR mRNA expression level in PBMCs also increased 1.41 ± 0.39-fold in non-DM-HD patients compared with that in healthy control subjects (p < 0.001). Although plasma prorenin level did not correlate with plasma BNP level and plasma high-sensitivity C-reactive protein level, it significantly correlated with plasma 8-hydroxydeoxyguanosine (8-OHdG) level (r = 0.535, p < 0.001). The plasma prorenin level did not correlate with plasma renin activity (PRA), plasma angiotensin I (AT I) level, plasma angiotensin II (AT II) level and plasma aldosterone (Ald) level. PRA, plasma AT I level, plasma AT II level and plasma Ald level did not correlate with the level of any CVD predictive biomarker. (P)RR expression level in PBMCs did not correlate with the level of any CVD predictive biomarker., Conclusions: The plasma prorenin level and (P)RR expression level in PBMCs increased, and the plasma prorenin level was associated with plasma 8-OHdG level independent of circulating RAS in non-DM-HD patients.

The renin-angiotensin-aldosterone system (RAAS) has pivotal roles in the pathogenesis of hypertension in hemodialysis-dependent chronic kidney disease (HDD-CKD) patients. Activated RAAS also increases inflammatory mediators by directly increasing proinflammatory gene expression and by putting oxidative stress on the vascular endothelium. Both hypertension and inflammation are major risk factors for cardiovascular disease (CVD) in HDD-CKD patients. In this study, we assessed the efficacy of a direct renin inhibitor, aliskiren, on blood pressure (BP) and CVD predictive biomarkers, such as brain natriuretic peptide (BNP), high-sensitivity C-reactive protein (hs-CRP) and diacron-reactive oxygen metabolite (d-ROM). A total of 30 hypertensive HDD-CKD patients were assigned to receive aliskiren (150 mg) orally once daily with their existing antihypertensives. After 8 weeks, aliskiren treatments reduced systolic blood pressure (SBP) from 169.0±20.1 to 153.7±19.6 mmHg (P<0.001) and diastolic blood pressure (DBP) from 78.1±12.0 to 73.0±13.6 mmHg (P=0.048). RAAS was suppressed by aliskiren treatment as follows: PRA (from 3.6±4.0 to 1.0±1.5 ngml(-1)h(-1) (P=0.004)), angiotensin I (from 1704.0±2580.9 to 233.7±181.0 pgml(-1) (P=0.009)), angiotensin II (from 70.2±121.5 to 12.4±11.5 pgml(-1) (P=0.022)) and aldosterone (from 107.9±148.0 to 73.1±34.6 pgml(-1) (NS)). The biomarkers for CVD were inhibited by aliskiren: BNP (from 362.5±262.1 to 300.0±232.0 pgml(-1) (P=0.043)), hS-CRP (from 6.2±8.1 to 3.5±3.7 mgl(-1) (P=0.022)) and d-ROM (from 367.0±89.8 to 328.3±70.9 U.CARR (P=0.022)). The inhibition levels of biomarkers for CVD by aliskiren did not correlate with the decreased levels of SBP and DBP. These results suggested that aliskiren was effective for BP control and may have cardiovascular protective effects in hypertensive HDD-CKD patients., (© 2011 The Japanese Society of Hypertension All rights reserved)

We developed a new optical device (Nikkiso) to assess changes through blood volume monitoring (BVM) during hemodialysis and were able to determine the ideal levels in which changes in blood volume percentage (BV%) occur among hemodialysis patients in one hemodialysis center. We evaluated both the reliability of BVM and these ideal levels in a multicenter group. The purpose of this manuscript is to develop a navigating system to set dry weight in a variety of situations as the final goal. First, based on the obtained BVM (BV%(BVM) ) measurements, the relationships between BV% and hematocrit (BV%(HT) ) and between BV% and CRIT-LINE (BV%(CLM) ; Hema Metrics, Kaysville, UT, USA) were then evaluated. In 30 hemodialysis patients, there was a close correlation between both BV%(BVM) vs. BV%(HT) and BV%(BVM) vs. BV%(CLM) (n=30, r=0.967, P<0.001, and n=36, r=0.7867, P<0.001, respectively). Second, BV% data were obtained from 464 treatment cases performed on 26 subjects in one satellite hemodialysis center on patients whose body weight was deemed clinically suitable. The formulas for the levels of BV% (standardized by the percent change in body weight at the end of hemodialysis treatment: BW%end) were determined. Finally, we revalidated the reliability of the above levels. A total of 1126 measurements were performed on 201 patients whose body weights were deemed suitable in seven hemodialysis centers. New ideal levels were then recalculated. We therefore conclude that BVM is a sufficiently accurate method of monitoring BV% in hemodialysis treatment. Most well-controlled hemodialysis patients display the same pattern of BV%/BW%end. Monitoring BV% during hemodialysis is beneficial for determining dry weight (DW)., (© 2010 The Authors. Journal compilation © 2010 International Society for Apheresis.)

A double-blind, placebo-controlled study was conducted to evaluate the efficacy, safety, and utility of TSUMURA Orengedokuto Extract Granules for Ethical Use (TJ-15) as a treatment for the accessory symptoms of hypertension. Two capsules of the study drug were administered orally 3 times daily (i.e., before meals) for 8 weeks. Among 265 patients enrolled in the study, 134 were assigned to the TJ-15 group and 131 were assigned to the placebo group, of whom 204 patients (103 in the TJ-15 group and 101 in the placebo group) were included in the efficacy and utility analyze and 251 patients (128 in the TJ-15 group and 123 in the placebo group) were included in the safety analysis. Efficacy was significantly higher in the TJ-15 group based on the total score for the accessory symptoms of hypertensions which was the primary efficacy endpoint (Wilcoxon's rank sum test, p=0.013). When each accessory symptom of hypertension was assessed separately, efficacy was higher for hot flushes and facial suffusion in the TJ-15 group (Wilcoxon's rank sum test, p=0.034, and 0.022, respectively). There were no significant differences between the TJ-15 and the placebo groups with respect to the decrease of blood pressure or the antihypertensive effect. There was also no significant difference between the two groups with regard to the overall safety rating. The utility rating was significantly higher in the TJ-15 group than in the placebo group (Wilcoxon's rank sum test, p=0.016). In conclusion, TJ-15 was superior to placebo with respect to efficacy, safety, and utility for the treatment of accessory symptoms of hypertension.

In encapsulating peritoneal sclerosis (EPS), matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases are involved in the remodeling of peritoneal tissue. We measured the MMP-2 concentration in the peritoneal effluents of a patient with EPS who discontinued continuous ambulatory peritoneal dialysis (CAPD) therapy because of ultrafiltration failure and/or underdialysis. First, we report a 58-year-old female patient who discontinued CAPD therapy because of underdialysis. Several months after cessation of CAPD, she complained of slightly blood-colored ascites and had an elevated level of C-reactive protein (CRP) in plasma. She was diagnosed as having clinical early-stage EPS. Peritoneal effluents drained from this case, and from 11 patients who discontinued CAPD therapy because of ultrafiltration failure and/or underdialysis, and who underwent peritoneal lavage with 1.5% dextrose peritoneal dialysis fluid for several months, were analyzed by gelatin zymography. MMP-2 concentration was also measured by enzyme-linked immunosorbent assay (ELISA). MMP-2 concentration in peritoneal effluent of this patient was highest compared with that of the other patients. There was some tendency of a positive correlation between MMP-2 concentration per 1 g protein and D/Pcr, and was negative correlation between MMP-2 concentration per 1 g of protein and D/D0 glucose. We concluded that MMP-2 is involved in the peritoneal remodeling of long-term CAPD therapy and the progression of EPS.

Background: Urinary tract obstruction induces renal damage, including not only interstitial fibrosis but also total loss of tissue integrity in the obstructed kidney. These processes require degradation and remodeling of the extracellular matrix. In the present study, we examined changes in matrix metalloproteinase-2 (MMP-2), a proteolytic enzyme, in a unilateral ureteral obstruction rat kidney model., Methods and Results: Gelatin zymography showed that the both mature and the immature forms of MMP-2 were increased in the obstructed renal cortex. We used real-time reverse transcription polymerase chain reaction (RT-PCR) for the quantification of mRNA expression. MMP-2 mRNA was upregulated in the ligated kidney and peaked on day 3 after obstruction, while, in contrast, MMP-9 mRNA was significantly decreased. Type 1- and type 2-tissue inhibitors of metalloproteinase were increased throughout the experimental period. RT-PCR showed a concomitant increase in the mRNA expression of membrane type-1 MMP (MT1-MMP) and extracellular MMP inducer (EMMPRIN)., Conclusions: We conclude that MMP-2 production in the renal cortex is increased in the early phase of ureteral obstruction and could be involved in the damage induced by ureteral obstruction.

Background and Purpose: Some previous Japanese cohort studies failed to show an association between smoking and stroke risk. Because such an association has been noted in other populations, this issue should be re-examined in a recent representative Japanese cohort with a higher total cholesterol level., Methods: A total of 9638 men and women aged 30 years and older without a history of cardiovascular disease (CVD) at baseline in 1980 were followed-up for 14 years., Results: We observed 203 stroke deaths (107 cerebral infarctions, 45 cerebral hemorrhages, and 51 others), 191 heart disease deaths, and 413 CVD deaths. The average serum total cholesterol level was approximately 4.91 mmol/L. Cox proportional hazard ratios were calculated adjusting for age, systolic blood pressure, and other conventional risk factors. The hazard ratios for men who smoked 1 to 20 cigarettes/day for all strokes, cerebral infarction, and cerebral hemorrhage were 1.60 (95% CI, 0.91 to 2.79), 2.97 (CI, 1.27 to 6.98), and 0.42 (CI, 0.16 to 1.09), respectively, and for those who smoked > or =21 cigarettes/day, they were 2.17 (CI, 1.09 to 4.30), 3.26 (CI, 1.11 to 9.56), and 0.68 (CI, 0.20 to 2.33), respectively. For women who smoked > or =21 cigarettes/day, the hazard ratio for all strokes was 3.91 (CI, 1.18 to 12.90). For CVD, all heart disease, and ischemic heart disease, the hazard risks of smoking were significant (1.49 to 4.25) for men but not significant for women., Conclusions: Smoking in a cohort with moderate serum total cholesterol level was a potent risk factor for stroke, especially cerebral infarction, for both men and women, and for CVD and ischemic heart disease for men.

We stratified findings from the Japan Multicenter Investigation for Cardiovascular Diseases-B according to whether or not the patients had diabetes and compared the incidence of cardiac events occurring over a 3-year period between treatment with nifedipine retard and angiotensin converting enzyme (ACE) inhibitor. The primary endpoint was the overall incidence of cardiac events (cardiac death or sudden death, myocardial infarction, hospitalization for angina pectoris or heart failure, serious arrhythmia, and coronary interventions), and the secondary endpoints were a composite of other events (cerebrovascular accidents, worsening of renal dysfunction, non-cardiovascular events, and total mortality). The results showed no significant difference in the incidence of the primary endpoint between the nifedipine group (n=199) and the ACE inhibitor group (n=173) in diabetic patients: 15.08% vs. 15.03%, relative risk 1.06, p=0.838. Also in nondiabetic patients, no significant difference was observed between the former (n=629) and the latter (n=649): 13.67% vs. 12.33%, relative risk 1.04, p=0.792. Similar results were obtained for the incidence of the secondary endpoints: in diabetic patients, 5.03% vs. 5.20%, relative risk 0.89, p=0.799; in nondiabetic patients, 2.70% vs. 2.47%, relative risk 1.07, p=0.842. Achieved blood pressure levels were 138/76 and 136/77 mmHg in the nifedipine group and 140/78 and 138/79 mmHg in the ACE inhibitor group in diabetic and nondiabetic patients, respectively. This study showed that nifedipine retard was as effective as ACE inhibitors in reducing the incidence of cardiac events in extremely high-risk hypertensive patients with complications of diabetes and coronary artery disease.

MC (mesangial cell) proliferation is closely linked to the progression of glomerular disease. It has been reported that cAMP effectors suppress MC proliferation, inhibiting activation of MAPK (mitogen-activated protein kinase). In fibroblasts, activation of MAPK induces the expression of type D cyclin, whereas, in MCs, this induction has not been shown. In the present study, we explored the effects of cAMP on MAPK and expression of cell-cycle-regulated proteins. PDGF (platelet-derived growth factor) stimulated MAPK activity, up-regulated protein levels of cyclin D1, CDK2 (cyclin-dependent kinase 2) and PCNA (proliferating cell nuclear antigen), decreased the protein level of p27 and increased DNA synthesis. Fsk (forskolin) or PD98059 suppressed PDGF-induced DNA synthesis. Both agents inhibited PDGF-stimulated mRNA and protein expression of cyclin D1 and CDK2. Fsk or PD98059 also inhibited protein expression of PCNA and blocked a decrease in p27 protein. Fsk induced the phosphorylation of Raf-1 at Ser259, which was inhibited by KT5720. These data suggest that cAMP inhibits MC proliferation through inhibition of MAPK activity, and this mechanism partly involves alteration in the levels of cell-cycle-regulated proteins.

The Japan Multicenter Investigation for Cardiovascular Diseases-B was performed to investigate whether nifedipine retard treatment was associated with a significantly higher incidence of cardiac events than angiotensin converting enzyme inhibitor treatment in Japanese patients. The study used a prospective, randomized, open, blinded endpoint (PROBE) design. Patients were enrolled at 354 Japanese hospitals specializing in cardiovascular disease. The subjects were 1,650 outpatients aged under 75 years who had diagnoses of both hypertension and coronary artery disease. There were 828 patients subjected to intention-to-treat analysis in the nifedipine retard group and 822 patients in the angiotensin converting enzyme inhibitor group. The patients were randomized to 3 years of treatment with either nifedipine retard or angiotensin converting enzyme inhibitor. The primary endpoint was the overall incidence of cardiac events (cardiac death or sudden death, myocardial infarction, hospitalization for angina pectoris or heart failure, serious arrhythmia, and coronary interventions). The primary endpoint occurred in 116 patients (14.0%) from the nifedipine retard group and 106 patients (12.9%) from the angiotensin converting enzyme inhibitor group (relative risk, 1.05; 95% confidence interval, 0.81-1.37; p = 0.75). In the Kaplan-Meier estimates, there were no significant differences between the two groups (log-rank test: p = 0.86). The incidence of cardiac events and mortality did not differ between the nifedipine retard and angiotensin converting enzyme inhibitor therapies. Nifedipine retard seems to be as effective as angiotensin converting enzyme inhibitors in reducing the incidence of cardiac events and mortality.

Angiotensin II type-1 receptor blocker (ARB) and angiotensin-converting enzyme inhibitor (ACEI) have been thought to be effective for reducing proteinuria in patients with chronic glomerulonephritis. Recently, an additive effect of these two types of angiotensin blockers has been reported in patients with IgA nephropathy, but the mechanism responsible for the effect has not yet been determined. In this study, we examined additive effect of these two drugs in chronic glomerulonephritis patients. Ten patients with biopsy-proven primary glomerulonephritis (eight IgA nephropathy patients, two membranous nephropathy patients), non-nephrotic proteinuria (protein, 0.5 to 3.5 g/day) received candesartan cilexetil (2 or 4 mg) for 8 weeks. After the 8 weeks, a combination of perindopril erbumine (1 or 2 mg) and candesartan cilexetil was administered to the patients. Perindopril was stopped after the 8-week administration of the two drugs. Candesartan alone reduced proteinuria by 13%. Combination of these two drugs induced a more remarkable reduction of proteinuria (48%; p < 0.05 vs other periods). The decrease in mean blood pressure by the combination therapy was significantly correlated with the decrease in proteinuria. The combination of drugs also reduced the amount of urinary type-IV collagen excretion. An additive effect of ACEI and ARB on proteinuria and urinary type-IV collagen excretion was recognized in patients with chronic glomerulonephritis.

We previously reported that erythropoietin (Epo) has a mitogenic effect on rat vascular smooth muscle cells (VSMC) and that activation of the mitogen-activated protein kinase (MAPK) cascade is an important mediator for Epo-induced mitogenesis. An increase in intracellular cAMP has an antiproliferative effect on VSMC. We therefore hypothesized that cAMP effectors inhibit Epo-induced MAPK activation in rat VSMC. When we exposed VSMC to recombinant human Epo (rHuEpo), DNA synthesis was increased. Forskolin (Fsk) or cilostazol (Cil) decreased the DNA synthesis stimulated by rHuEpo. Coincubation with Rp-cAMPS triethylamine canceled the suppression of DNA synthesis and MAPK activity by Fsk. Both rHuEpo and phorbol 12-myristate 13-acetate upregulated phosphorylations of MEK and MAPK. Pretreatment with Fsk inhibited these phosphorylations. Protein kinase C inhibitors also suppressed MEK and MAPK phosphorylations. Moreover, Fsk induced phosphorylation of Raf-1 at serine-259. These results indicated that cAMP inhibited Epo-induced MAPK activation and that this suppression might be regulated upstream or at Raf-1. The results also suggested that these agents, which could accumulate cAMP, might be protective for Epo-stimulated direct action.

It has been reported that calcium deposition and calcium content in cultured human aortic smooth muscle cells (SMC) increased when the cells are incubated in a medium with a high phosphate concentration (2 mM). To determine the cellular components or soluble factors contributing to the deposition, we cultured commercially available SMC, fibroblasts (Fb) and endothelial cells (Ed). These cells and their mixtures were incubated for 10 days in normal or high-phosphate media. Calcium crystals were stained by the von-Kossa staining and counted in the defined area. Calcium content was measured by a colorimetric assay. SMC were incubated in high-phosphate media (up to 2 mM) or beta-glycerophosphate (beta-GP) media, resulting in no obvious deposition of calcium crystals, irrespective of the coating of type I collagen on the dish. Next, various combinations of cells were cultured, and a significant number of depositions were observed only when Fb were included in the combination. The calcium content was significantly higher in cultures of SMC and Fb. The calcium deposition on single or mixture of the cells did not increase compared with control when cells were incubated in a high concentration of phosphate, cultured in the existence of beta-GP or uremic serum. We therefore conclude that Fb, rather than SMC or Ed, are essential for calcium deposition and calcium accumulation in culture. Phosphate concentration in the medium and uremic serum did not influence the deposition of calcium., (Copyright 2002 S. Karger AG, Basel)

Recently, we found that hyperosmolality acutely inhibited atrial natriuretic peptide (ANP) dependent cGMP production by reducing ANP binding sites in cultured rat inner medullary collecting duct (IMCD) cells. Therefore, the present study was undertaken to evaluate the chronic effect of hyperosmolality on ANP dependent cGMPproduction in IMCD cells. Cell culture was carried out either in an iso-osmotic or hyperosmotic solution consisting of equi-isomolar NaCl and/or urea. Incubations with ANP and/or other agents were performed under the same osmotic conditions. ANP or SNP stimulated cGMP production was enhanced in a chronically hyperosmotic medium. These changes occurred in an osmolality-dependent manner. Hyperosmolality with sodium alone or with sodium and urea, but not with urea alone, was effective for the enhancement of ANP action. There was no significant difference between 125I-ANP specific bindings under iso-osmotic and hyperosmotic conditions. Incubation with cytoskeleton modulators did not affect ANP-dependent cGMP production stimulated by hyperosmolality. On the other hand, both actinomycin D, an inhibitor of transcription, and cycloheximide, an inhibitor of protein synthesis, prevented the stimulatory effects of hyperosmolality. The results suggest that chronic hyperosmolality enhances ANP-dependent cGMP production via stimulation of transcription and protein synthesis in cultured rat IMCD cells.

Interleukin-1beta (IL-1beta) stimulates nitric oxide (NO) production and induces apoptosis in several tissues. Cilostazol is a Type 3 phosphodiesterase inhibitor. We investigated whether cilostazol affects IL-1beta-induced NO production and apoptosis in rat vascular smooth muscle cells. Cilostazol (100 nM-10 microM) potentiated NO production triggered by IL-1beta. The mRNA and protein expression of inducible NO synthase was also upregulated by cilostazol. KT5720, an inhibitor of protein kinase A, and N(G)-monomethyl-L-arginine, an inhibitor of NO synthase, abrogated cilostazol-enhanced IL-1beta-stimulated NO production and apoptosis. These results shows that cilostazol potentiates IL-1beta-induced NO production via PKA-pathway and thereafter augments apoptosis via NO-dependent pathway.

It is well known that long-term glucocorticoid treatment causes osteoporosis, but the precise mechanism remains unclear. Recently, osteoprotegerin (OPG) has been identified as a cytokine that inhibits osteoclast differentiation. We have previously demonstrated that serum OPG is suppressed by glucocorticoids. Therefore, the present study was carried out to clarify the interrelationships between OPG and other markers of bone metabolism during glucocorticoid treatment. Thirteen patients (7 men, 6 women; 44.1 +/- 5.9 years old) with chronic glomerulonephritis who were to be treated with glucocorticoids for the first time were chosen for this study. Markers of bone metabolism, including serum OPG, osteocalcin (OC), bone-specific alkaline phosphatase activity (bAP), parathyroid hormone (PTH), tartrate-resistant acid phosphatase (TRAP), and bone mineral density (BMD), were measured before and during the treatment period. Glucocorticoids significantly reduced BMD of the lumbar spine in the 6 month treatment period (p < 0.01). Serum OPG was decreased significantly by glucocorticoids within 2 weeks (p < 0.001), and serum TRAP, a marker of bone resorption, was markedly increased (p < 0.001). On the other hand, there were no remarkable changes in serum PTH. Serum OC and bAP, markers of bone formation, were transiently reduced during the treatment period (p < 0.01). Furthermore, only serum OPG was positively and independently correlated with percentage BMD of age-matched reference (%AMR). These findings imply that glucocorticoid-induced bone loss develops rapidly via enhanced bone resorption and suppressed bone formation. Moreover, the increased bone resorption caused by glucocorticoids may be, at least in part, mediated by inhibition of OPG, not increment of PTH.

Background: Hemodialysis patients who had been treated with anti-platelet aggregation drugs, including ticlopidine, sometimes developed hypotension. The mechanism by which ticlopidine lowers the blood pressure in hemodialysis patients is unclear. To elucidate the mechanism of the action of this drug, we investigated cytokine-stimulated nitric oxide (NO) metabolism by ticlopidine in cultured rat vascular smooth muscle cells (VSMC)., Methods: Nitrite, a stable metabolite of NO, and intracellular cAMP and cGMP contents were assayed by the Griess method and enzyme immunoassay, respectively. iNOS mRNA and protein expressions were analyzed by Northern blotting and Western blotting., Results: Ticlopidine enhanced interleukin-1beta (IL-1beta)-induced nitrite production in a dose- and time-dependent manner. The mRNA and protein expressions of inducible NO synthase were upregulated by ticlopidine in a dose- and time-dependent manner. IL-1beta alone stimulated both intracellular cAMP and cGMP contents, and the addition of ticlopidine further enhanced their contents. KT 5720, a selective inhibitor of protein kinase A, but not KT 5823, a selective inhibitor of protein kinase G, abolished the enhancement of IL-1beta-induced nitrite production by ticlopidine. In addition, a phosphodiesterase inhibitor, isobutylmethylxanthine, enhanced IL-1beta and ticlopidine induced nitrite production., Conclusion: We concluded that ticlopidine enhanced the IL-1beta-induced NO production via cAMP and subsequent activation of protein kinase A in cultured rat VSMC., (Copyright 2002 S. Karger AG, Basel)

A randomized prospective controlled study, the National Interventional Cooperative Study in Elderly Hypertensives (NICS-EH), previously demonstrated that the preventive effect of the long-acting calcium channel blocker nicardipine on the cardiovascular endpoint was similar to that of the diuretic, trichlormethiazide. The present report is a sub-analysis in which we compare the tolerability and safety of the calcium channel blocker with that of a diuretic in the long-term treatment of elderly hypertensives. A total of 429 elderly patients with hypertension were assigned to the nicardipine group or the diuretic group by the double-dummy method and were followed up for 5 years. Two hundred four patients in the nicardipine group and 210 patients in the diuretic group were analyzed. The incidences of fatal and nonfatal cardiovascular (CV) events in the two groups were comparable, and there was no significant difference in the cumulative event-free rate. However, the total incidence of adverse reactions, including non-CV events and unfavorable BP changes, was 31 cases (15.2%) in the nicardipine group, which was significantly lower than the 47 cases (22.4%) in the diuretic group (log-rank: p=0.026, G. Wilcoxon: p=0.01). The total number of medical endpoints, including CV events, the withdrawal of the patient from the study, was 52 (25.5%) in the nicardipine group, which was significantly lower than the 65 (31.0%) in the diuretic group (log-rank: p=0.078, G. Wilcoxon: p=0.044). It was concluded that sustained-release nicardipine is better tolerated, as it exhibits a lower incidence of medical-related withdrawals such as adverse drug reactions, non-cardiovascular events and unfavorable BP responses during the treatment.

Background: Recent studies have shown that several cytokines could induce apoptosis in vascular smooth muscle cells (VSMCs) via the induction of nitric oxide (NO). In the present study, we explored whether human recombinant erythropoietin (rHuEPO) has a modulatory effect of apoptosis on interleukin-1beta (IL-1beta) or NO donor sodium nitroprusside (SNP)-induced apoptosis in rat cultured VSMCs., Methods: The quantitation of apoptosis among VSMCs was assessed by nuclear morphological analysis with fluorescent DNA-binding dye Hoechst 33258. Apoptotic changes were also confirmed by the detection of DNA fragmentation. The expression of EPO receptor (EpoR), cellular protein tyrosine phosphorylation, including EpoR and Janus kinase (JAK) 2, and the association of p85 subunit of phosphatidylinositol 3 kinase (PI3-kinase) to tyrosine-phosphorylated proteins, including EpoR, were explored by using Western blotting analysis combined in part with immunoprecipitation., Results: rHuEPO inhibited the apoptosis induced by IL-1beta or SNP in a dose- and time-dependent manner. The anti-apoptotic effects of rHuEPO were diminished in the presence of a tyrosine kinase (TK) inhibitor genistein or anti-EpoR antibody. After stimulation with rHuEPO, EpoR and JAK 2 were tyrosine phosphorylated, and p85 subunits were associated with EpoR. Also, rHuEPO induced phosphorylation of Akt through a PI3-kinase-dependent pathway. The phosphorylation of Akt and the anti-apoptotic effects of rHuEPO were diminished in the presence of a PI3-kinase inhibitor, wortmannin., Conclusion: Our present study demonstrates that rHuEPO inhibites IL-1beta or SNP-induced VSMC apoptosis. The TK-dependent pathway, particularly the PI3-kinase-dependent pathway, seems to be critical to the countervailing effect of rHuEPO on IL-1beta and SNP-induced VSMC apoptosis.

To compare the incidence of cough between two angiotensin converting enzyme (ACE) inhibitors, imidapril and enalapril, comparative crossover study was performed in 489 patients (228 men and 261 females) with essential or renal parenchymal hypertension. Patients were randomly assigned to one of two treatment groups, a group receiving imidapril for 12 wk (Period I) followed by enalapril for 12 wk (Period II), and a group in which the order of drugs was reversed. The occurrence of cough during treatment was monitored by questionnaire in all cases. There were no differences in background characteristics between the two groups. The incidence of cough during Period I was 15.2% (32/210) in the group initially treated with imidapril (Group IE) and 38.6% (85/220) in the group initially treated with enalapril (Group EI), the difference being statistically significant (p < 0.001). During Period I, decrease in blood pressure was observed in 63.9% (115/180) of Group IE and 64.6% (115/178) of Group EI patients. In approximately half of the patients in Group EI who developed cough during Period I and in whom the treatment was subsequently switched to imidapril, cough subsequently disappeared. It was concluded that the incidence of cough was significantly less under imidapril than under enalapril treatment, while there was no difference in the antihypertensive effects of the two ACE inhibitors.

Background: Interstitial fibrosis and the development of renal cysts are crucial phenomena in renal disease progression. While 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors has been shown to reduce the progression of several experimental nephropathies, the mechanism of their potential protective effect remaines unclear., Methods: The antiproliferative, apoptotic, and fibrinolytic effects of HMG-CoA reductase inhibitors were assessed in primary cultured rat (rPTCs) and mouse proximal tubule cells (mPTCs), in isolated rat proximal tubules, and in vivo in 5/6 nephrectomized rats (Nx)., Results: In vitro, lovastatin inhibited rPTC proliferation in a manner selectively prevented by mevalonate, farnesyl-, or geranylgeranyl-pyrophosphate (FPP or GGPP). Lovastatin reduced membrane-bound p21ras and fetal calf serum-induced c-fos and c-jun protein expression. Gel shift assay showed that lovastatin reduced activated protein-1 (AP-1) binding activity. In vivo, lovastatin inhibited tubular cell proliferation after Nx, as measured by proliferative cell nuclear antigen staining. Lovastatin-treated mPTCs displayed nucleus cleavage and DNA ladder formation, which were prevented by GGPP. Like C3 exoenzyme, lovastatin induced actin filament disruption, which preceded evidence of apoptosis. Lovastatin increased tissue-type plasminogen activator (PA) and decreased PA inhibitor activities and antigens; these effects were prevented by mevalonate and GGPP but not FPP, and were reproduced by C3 exoenzyme in a manner insensitive to GGPP., Conclusions: HMG-CoA reductase inhibitors decreased proliferation, increased apoptosis, and enhanced fibrinolytic activity of renal tubular cells via modulation of different isoprenylated proteins. These effects could participate to reduce the progression of renal diseases.

Objective: To elucidate the effect of atrial natriuretic peptide (ANP) on cytokine-induced nitric oxide (NO) production, we examined whether ANP affects IL-1 beta-stimulated NO production and inducible NO synthase (iNOS) mRNA expression in cultured rat vascular smooth muscle cells (VSMC)., Methods: VSMC were incubated with test agents for 24 h. The nitrite concentration of the culture medium, a stable-end product of NO, was measured by the column reduction method. NOS mRNA expression was analyzed by Northern blotting. The intracellular cAMP content was measured by enzyme immunoassay. cAMP-dependent kinase (PKA) activity was determined by a PKA assay system., Results: IL-1 beta stimulated nitrite production in VSMC. ANP (10 nM to 1 mM) enhanced the nitrite production and iNOS mRNA expression in the presence of IL-1 beta. Both 8-bromo-guanosine 3',5'-cyclic monophosphate (8-br-cGMP) and dibutylyl adenosine 3',5'-cyclic monophate enhanced IL-1 beta-induced nitrite production. The effects of these two nucleotide donors on the nitrite production were not additive, suggesting a common pathway. KT 5720, an inhibitor of PKA, abolished the enhancement of nitrite production by ANP and 8-br-cGMP, while KT 5823, an inhibitor of cGMP-dependent protein kinase, did not inhibit the enhancement. In the in vitro assay 8-br-cGMP increased PKA activity., Conclusions: ANP and cGMP enhanced IL-1 beta-induced NO production in VSMC. PKA rather than PKG may be involved in the enhancement.

Renal cyst formation in polycystic diseases or after nephron reduction is attributed to enhanced tubular cell proliferation with unbalanced cell death. The induction of tubular cell death could be effective to reduce renal cyst formation. In this study, we examined the effects of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors on apoptosis in mouse proximal tubular (MPT) cells in primary culture. After treatment with HMG-CoA reductase inhibitors, the extracted DNA was analyzed by gel-electrophoresis under ultraviolet light. Apoptosis was evaluated quantitatively by estimating the ratio of fragmented DNA over intact DNA. For morphologic studies, cells were stained with Hoechst 33,258. DNA ladder pattern of 200 kDa typical of apoptosis and significant increase in DNA fragmentation were seen after 24 hours of treatment with lovastatin, a HMG-CoA reductase inhibitor. Staining with the Hoechst dye revealed cleavage of nucleus into pieces under the same condition. Geranylgeranylpyrophosphate (20 microM) and mevalonate (500 microM) completely reversed the effect of lovastatin, while farnesylpyrophosphate (20 microM) partially reversed it. Other products of HMG-CoA pathway such as cholesterol, ubiquinone, dolichol, and isopentenyladenine had no effect. Perillic acid and alpha-hydoxyfarnesylphosphonic acid, isoprenylation inhibitors, induced apoptosis of the cells. A treatment with lovastatin caused actin filament disruption. Cytochalasin D, an inhibitor of actin polymerization, induced apoptosis. Interleukin-1 beta-converting enzyme inhibitor II, a protease inhibitor, had no effect on the apoptosis induced by either HRI or cytochalasin D. The present study suggests that in mouse proximal tubules, HMG-CoA reductase inhibitors induce apoptosis via inhibition of isoprenoid production, and disruption of actin filaments may play a role in the apoptosis induction.

We present a case study of a 52-year-old female patient with hyperthyroidism which had been diagnosed at the age of 35. However, the malfunction of thyroid had been poorly controlled. Thyroid function was returning to normal after the administration of propylthiouracil (PTU) 300 mg/day, however purpura appeared in both lower extremities. Renal function deteriorated rapidly, and the patient was admitted to our hospital. According to the biopsies, leukocytoclastic vasculitis in the skin was apparent, and crescent formation was observed in the glomerulus. Serological examination revealed positive antineutrophil cytoplasmic autoantibodies (ANCA) against proteinase 3 (Pr3) and myeloperoxidase (MPO). Antinuclear autoantibody was positive. After cessation of PTU and administration of prednisolone, the purpura disappeared and ANCA were becoming negative. Renal function recovered gradually. Thyroid function was kept within normal range using iodine solution. Thus, it is strongly suggested that PTU-induced rapidly progressive glomerulonephritis associated with ANCA.

A new technique for time series analysis, which is a combination of the maximum entropy method (MEM) for spectral analysis and the non-linear least squares method (LSM) for fitting analysis, is described. In this technique, the MEM power spectral density (MEMPSD) is calculated using a very large lag that could diminish the lag dependence of dominant periods estimated by the MEM analysis. The validity of this large lag is confirmed by the LSM, given that the ten dominant MEM periods are known quantities. To validate the MEM plus LSM technique, it is compared with autoregressive (AR) modelling, by analysing heart rate variability under pharmacological interventions (phenylephrine and trinitroglycerine), using 16 young males. The results indicate that the MEMPSD, when compared with the ARPSD, has numerous periods that could reproduce the original time series much more accurately, as revealed by the LSM analysis. However, both the low- and high-frequency powers with MEMPSD and ARPSDs shift in the expected directions in accordance with the pharmacological effects on the cardiovascular system. The implications of these results are discussed from the theoretical and practical standpoints of the MEM plus LSM technique, compared with AR modelling.

To investigate current drug therapy for elderly hypertensive patients, we performed a case-card study at Sapporo Medical University and its branch hospitals. The case-card was designed to show prescriptions given for hypertension, complications, and blood pressure. In the 2897 valid cases, calcium antagonists were prescribed in 76.3%, followed by beta-blockers (31.4%), angiotensin-converting enzyme inhibitors (ACE-I) (25.1%) and natriuretic diuretics (18.1%). When the patients were divided into an elderly group (> or = 65 y.o., n = 1475), beta-blockers and ACE-I were found to be more frequently used in the non-elderly group, and diuretics were more frequently prescribed in the elderly group. Calcium antagonists were the most frequently used drugs, irrespective of age. As monotherapy drugs, calcium antagonists were chosen most frequently in both groups. Diuretics were the second most frequently used drug in the elderly group, but beta-blockers occupied that position in the younger group and these patients as a whole. In the elderly group, the manner of prescription was analyzed according to major complications. In patients with ischemic heart disease, beta-blockers and diuretics were used more frequently than in patients without that condition. Diuretics were prescribed more frequently in patients with renal dysfunction. Calcium antagonists and ACE-I were used more frequently in the patients with diabetes mellitus. The same differences were found in the non-elderly patients with those complications. However, among patients with stroke, calcium antagonists were more frequently used in the elderly group and ACE-I were performed in the younger patients. In conclusion, calcium antagonists were used very often regardless of age, and the other drugs were used according to age-dependent differences in pathophysiologic mechanism.

In our laboratory, it had been found that the renal natriuretic and depressor systems are suppressed in essential hypertension, and that suppression of the dopaminergic system may be primary and dominant in this condition. Moreover, close relationships among the renal dopamine, kallikrein-kinin, and prostaglandin systems have also been found. Therefore, we attempted to evaluate the pathogenetic and pathophysiological role of renal dopamine in connection with renal kallikrein-kinin and prostaglandin systems in various experimental hypertensive models. Two kidney 1 clip hypertensive rats (2K1C), 5/6 reduced renal mass hypertensive rats (5/6 RRM), deoxycorticosterone acetate-salt hypertensive rats (DOCA-salt), spontaneously hypertensive rats/Izumo (SHR/Iz), Dahl salt sensitive hypertensive rats/John Rapp (Dahl/Jr), Dahl/Iwai (Dahl/Iw), and respective controls were employed in this study. Urinary excretions of free dopamine (uDA), kallikrein (uKAL), and prostaglandin E2 (uPGE2) were measured before, during and after treatment in each of these hypertensive models. In these experimental hypertensive models, renal dopamine in DOCA-salt and SHR/Iz, and renal kallikrein in 2K1C, 5/6 RRM and two types of Dahl strains were primarily and dominantly suppressed in the renal natriuretic and depressor systems. Renal dopamine was transiently suppressed in Dahl/Jr, and PGE2 was suppressed in the two types of Dahl strains. Compensatory augmentation of renal kallikrein was found in DOCA-salt and SHR/Iz, and that of PGE2 was found in 5/6 RRM and DOCA-salt. Although these three renal natriuretic depressor systems are suppressed in Dahl/Jr, the dominantly suppressed system is not renal dopamine but renal kallikrein. Thus, it was summarized that, 1) decreased renal dopamine production is important in the pathogenesis of human essential hypertension, 2) pressor mechanisms of experimental hypertensive rats are different from human essential hypertension, 3) decreased renal dopamine is important in DOCA-salt and SHR/Iz, 4) decreased renal kallikrein is the dominant mechanism in the pathogenesis of 2K1C, 5/6 RRM, Dahl/Jr and Dahl/Iw hypertensive rats, and 5) we have to be careful when considering human essential hypertension through results taken from experimental rat hypertensive models.

Objectives: To investigate the role of kinin in preconditioning against infarction, the present study assessed the effect of captopril, a kininase II inhibitor, on preconditioning and arterial plasma kinin levels., Background: Recent studies suggest a possible contribution of kinin to preconditioning against infarction. However, its role and the site of kinin production remain uncharacterized., Methods: Six groups of rabbits (n = 6 to 13) underwent 30-min coronary occlusion and 3-h reperfusion. The infarct size and area at risk were determined by tetrazolium staining and fluorescent particles, respectively. Arterial blood was sampled under baseline conditions, before the 30-min ischemia and after reperfusion for radioimmunoassay of the kinin level., Results: Infarct size expressed as a percentage of area at risk (%IS/AR) was 42.9 +/- 2.9% (mean +/- SEM) in the control group, 34.5 +/- 3.3% in the group preconditioned with 2 min of ischemia/5 min of reperfusion and 41.7 +/- 5.1% in the group given captopril (1 mg/kg body weight) alone before the 30-min ischemia. These %IS/AR values were not significantly different between the three groups. However, a combination of captopril and subsequent preconditioning with 2 min of ischemia markedly limited %IS/AR to 21.2 +/- 2.4%. This potentiation of 2 min of preconditioning by captopril was not observed when 2 micrograms/kg body weight of Hoe 140, a specific bradykinin B2 receptor antagonist, was administered before preconditioning (%IS/AR = 41.2 +/- 5.7%), whereas Hoe 140 alone did not modify infarct size (%IS/AR = 38.5 +/- 5.1%). Arterial plasma kinin levels were comparable between the control rabbits, the group given captopril alone and the group that received captopril plus 2 min of preconditioning at baseline (3.8 +/- 1.0, 6.3 +/- 1.9 and 5.2 +/- 1.7 pg/ml, respectively), and there was no significant change in kinin levels after the captopril injection or the combination of captopril plus 2 min of preconditioning., Conclusions: The present results indicate that captopril is capable of potentiating preconditioning without increasing the arterial kinin level and that the beneficial effect of captopril can be inhibited by Hoe 140. These findings support the hypothesis that kinin produced locally in the heart during preconditioning may contribute to the cardioprotective mechanism through bradykinin receptor activation.

Although the pathogenesis of essential hypertension still remains unclear, it is now generally accepted that the kidney is deeply involved in the pathophysiology of this disease. This paper therefore, reviews current knowledge of the role of renal dopaminergic activity in essential hypertension. This is believed to be one of the most important renal diuretic and depressor systems. Suppression of urinary excretion of free dopamine (DA) is observed in essential hypertensives, particularly in those with low plasma renin activity (LRH) who demonstrate body fluid volume expansion. An increased natriuretic response to exogeneously administered DA is found, particularly in LRH, and suppressed biosynthesis of DA from L-dopa in the kidney has been suggested. Furthermore, this suppression of renal dopaminergic activity was also observed in young normotensive subjects with an apparent family history of hypertension before any evidence of hypertension emerged. From these findings, it is concluded that the decrease in renal dopaminergic activity is involved, at least in part, not only in the pathophysiology of essential hypertension, but also in the pathogenesis of this disease.

Preconditioning is known to decelerate degradation of the tissue adenine nucleotides during ischemia and to delay ischemic myocardial necrosis. However, it is not known whether these two phenomena are related. To obtain an insight into this question, the present study examined whether adenosine and B2 receptor antagonists, which block the infarct size-limiting effect of preconditioning, modify the interstitial purine levels during preconditioning and subsequent sustained ischemia. In pentobarbital anesthetized open-chest rabbits, a microdialysis probe was placed in the territory of a branch of the left coronary artery, and perfused with Ringer solution. Preconditioning was performed with 5 min ischemia/5 min reperfusion. Dialysate adenosine and inosine were elevated from the baseline values of 0.064 +/- 0.011 and 0.329 +/- 0.044 microM to 0.189 +/- 0.069 and 4.106 +/- 1.451 microM, respectively during preconditioning, but their elevation during a subsequent 20 min of ischemia was significantly lower compared with that in the non-preconditioned myocardium. This suppression of the purine accumulation during ischemia by preconditioning was not abolished by 2 micrograms/kg of Hoe 140, a specific B2 receptor antagonist, or by 10 mg/kg of 8-phenyltheophylline, a non-selective adenosine receptor antagonist. Since the doses of Hoe 140 and 8-phenyltheophylline are sufficient to block the infarct size-limiting effect of preconditioning, the present results suggest that there is a dissociation between the suppression of adenine nucleotide degradation during ischemia by preconditioning and the enhancement of myocardial resistance against infarction. Thus, it is unlikely that a reduction of adenine nucleotide utilization by preconditioning is sufficient to protect the myocardium against ischemic necrosis.

A case of a 58-year-old man with bilateral deoxycorticosterone (DOC)-secreting adrenocortical adenoma is reported. Before surgery, plasma levels of DOC and corticosterone were markedly elevated, but both adrenal hormone levels normalized after the surgical removal of the bilateral adrenal tumors. The histologic examination revealed bilateral adrenocortical adenoma, but curiously, the tissue concentrations of DOC and corticosterone were elevated only in the right adrenal gland.

Metabolic imaging using 123I-labeled 15-(p-iodophenyl)-3-R,S-methylpentadecanoic acid (BMIPP) and Fourier phase analysis of gated blood-pool data were performed in a 60-yr-old woman with idiopathic hypertrophic cardiomyopathy. Dyskinetic wall motion was identified as a markedly delayed phase angle in the left ventricular apex, which was well perfused but highly hypertrophied like other ventricular segments. Fatty acid imaging, however, clearly demonstrated highly reduced activities in the apex, although there were no abnormalities in regional systolic function or in 201TI uptake in other hypertrophied regions. Contrast left ventriculography revealed a midventricular collapse of the left ventricle at end-systole due to markedly hypertrophied ventricular walls and dyskinesis at the apex. Thus, dyskinetic wall motion in the apex closely correlated not only with cardiac hypertrophy but also with impaired fatty acid uptake. These findings were unrelated to the myocardial perfusion state per se. Fatty acid imaging using BMIPP may contribute to the detection of myocyte degeneration not visible using conventional imaging modalities. It may also provide etiological information on regional dysfunction in hypertrophic cardiomyopathy.

1. The role of the renal dopaminergic system in water-sodium metabolism in heart failure remains unclear. 2. In this study, the urinary free dopamine excretion (uDA), delivery of L-dopa to renal proximal tubules (plasma L-dopa x creatinine clearance (Ccr)), and the production of dopamine in the kidney [uDA/(plasma L-dopa x Ccr)] were investigated in patients with congestive heart failure (n = 30) and in normal controls (n = 12). In both groups, endogenous Ccr, urinary excretion of sodium (UNaV), fractional excretion of sodium (FENa), plasma noradrenaline concentration (pNA) and plasma L-dopa concentration were also estimated. 3. uDA, plasma L-dopa, delivery of L-dopa and dopamine production in the kidney showed successively lower values in congestive heart failure with progression in NYHA functional class. 4. UNaV (r = 0.458, P < 0.05) and Ccr (r = 0.539, P < 0.01) positively correlated with uDA. Linear correlations were found between left ventricular ejection fraction and uDA (r = 0.574, P < 0.01), pNA (r = -0.495, P < 0.01) or plasma L-dopa (r = 0.423, P < 0.05). 5. From these findings, it was suggested that (i) uDA was clearly suppressed in patients with CHF, and (ii) the possible mechanisms of its suppression might be due to decrease of delivery of L-dopa into the proximal tubules and suppressed production of dopamine from L-dopa in the kidney.

The present study endeavors to correlate regional myocardial sympathetic nerve dysfunction with reversible and persistent perfusion abnormalities and depressed regional wall motion, and to determine the diagnostic efficacy of radio-iodinated metaiodobenzylguanidine (MIBG) tomography for detecting coronary artery disease. In 28 consecutive patients with stable coronary artery disease and 7 patients with atypical chest pain but no coronary stenosis, regional MIBG uptake was semiquantitatively evaluated in 13 left ventricular segments early (30 minutes) and late (4 hours) after injection. Regional MIBG uptake was reduced in 68 of 90 segments (76%) showing reversible perfusion abnormality and 72 of 81 segments (89%) showing persistent abnormality 4 hours after injection. Although the sensitivity and negative predictive values of late MIBG scanning for detecting myocardial perfusion abnormalities were relatively high (82% and 85%, respectively), the specificity, positive predictive value, and kappa value were low (63%, 57%, and 0.41, respectively). Right coronary lesions were detected by late MIBG scanning with a high sensitivity (85%) but a low specificity (41%). Conversely, the sensitivities for detecting lesions in the other 2 major left coronary arteries were low (55%). The overall diagnostic accuracy of late MIBG scanning was 66% and the positive and negative predictive values and kappa value were low; 60%, 70%, and 0.31, respectively. Similarly, regional sympathetic dysfunction was observed in 42 of 49 asynergic segments (86%) on late MIBG scans, of which 32 segments were viable and 10 nonviable; but the low specificity (73%) and positive predictive value (44%) reduced the kappa value (0.43). Thus, regional cardiac sympathetic innervation is impaired in ischemic, asynergic but noninfarcted myocardium as well as in myocardium which is infarcted or has a persistent perfusion abnormality. The diagnostic efficacy of MIBG tomography to detect coronary artery disease, however, is limited probably because of nonspecific reductions of MIBG uptake in the inferior and posterolateral regions.

In this article, some of our findings of epidemiologic and clinical studies on the actual state of insulin resistance in hypertension occurring in Japanese were described. In epidemiologic studies, a high prevalence of concomitant hypertension and impaired glucose tolerance was observed, and a significant positive correlation was found between blood pressure and blood glucose levels, even at a low degree, in two towns, the agricultural districts of Hokkaido. In clinical studies, insulin sensitivity, which was measured as M-values by the euglycemic hyperinsulinemic glucose clamp method, was significantly lower in essential hypertensives than in normotensive subjects. Moreover, this suppression of insulin sensitivity was also observed in young normotensive subjects with an apparent family history of hypertension, preceding the manifestation of hypertension. At the same time, obesity and aging were definitely correlated to the decrease in insulin sensitivity. On the assumed criterion that the normal range of M-values is mean +/- 1 SD of non-obese, non-diabetic young normotensive subjects, the prevalence of individuals with lowered M-value, which means existence of insulin resistance, was calculated as 45.4% in essential hypertensives and as 16.3% in normotensive subjects in this study. Increases in plasma norepinephrine levels and plasma renin activity, and decreases in urinary excretion of sodium and fractional excretion of sodium were observed during hyperinsulinemia produced by glucose clamp test. These responses to hyperinsulinemia were not different from those in normotensive subjects and, therefore, not specific to essential hypertensives. From these results, it was concluded that insulin resistance definitely exists among Japanese essential hypertensives, and that it plays an important role in the pathophysiology of essential hypertension.

We investigated the effect of adenosine 3', 5'-cyclic monophosphate (cAMP) on inducible nitric oxide synthase (iNOS) expression in cultured neonatal rat cardiac myocytes. Incubation of cardiac myocytes for 24 h with interleukin-1 beta (IL-1 beta) caused a significant increase in the production of nitrite, a stable metabolite of nitric oxide. Dibutyl cAMP (db-cAMP) significantly augmented nitrite production by IL-1 beta-stimulated, but not by unstimulated cells, in a dose-dependent manner. db-cAMP also dose dependently increased nitrite production by tumor necrosis factor-alpha(TNF-alpha)-stimulated cells. Simultaneous incubation with NG-monomethyl-L-arginine completely inhibited the effect of db-cAMP on nitrite production. cAMP-induced nitrite production by cytokine-stimulated cells was accompanied by increased iNOS mRNA accumulation. The synergistic effect of cAMP on IL-1 beta-induced nitrite accumulation was mimicked by cAMP-generating agonists forskolin and isoproterenol. These results indicate that cAMP upregulates cytokine-induced iNOS expression in cardiac myocytes.

1. In the present study, using the euglycaemic hyperinsulinaemic glucose clamp technique, we investigated the effects of hyperinsulinaemia on sodium-water metabolism and the pressor system in obesity, both of which have been reported to be closely associated with insulin resistance and/or hyperinsulinaemia. 2. Sixteen obese young subjects and 24 non-obese young subjects who were all normotensives, participated in this study. The 2 h euglycaemic hyperinsulinaemic glucose clamp was performed in a fasting state. The mean glucose infusion rate needed to maintain a fasting blood sugar level (FBS) during the last 30 min of the clamp was used as an indicator of insulin sensitivity (M-value). Before and after the clamp, the following parameters were measured: creatinine clearance (Ccr); urinary excretion of sodium (UNaV); fractional excretion of sodium (FENa); plasma renin activity (PRA); plasma aldosterone concentration (PAC) and plasma noradrenaline concentration (PNA). 3. The M-value was significantly lower in obese subjects compared with non-obese subjects, although FBS and fasting immunoreactive insulin levels were similar in both groups. UNaV and FENa fell only in obese subjects during the clamp, while Ccr showed no significant change in either group. PNA and PRA increased significantly and PAC tended to increase in both groups. 4. These results suggest that obese subjects have insulin resistance with respect to glucose metabolism, but that urinary sodium excretion and the pressor system remain insulin-sensitive; the sensitivity of the sodium retaining action to hyperinsulinaemia was actually higher in obese subjects than in non-obese subjects. Therefore, if compensatory endogenous hyperinsulinaemia was raised by insulin resistance, these two factors may lead to chronic sodium retention and pressor system stimulation and, in turn, to hypertension in obesity.

We examined whether dipyridamole affected interleukin-1beta-stimulated nitric oxide (NO) production by cultured rat vascular smooth muscle cells. Interleukin-1beta stimulated the production of nitrite and nitrate, stable metabolites of NO, in a dose- and time-dependent manner in vascular smooth muscle cells. Dipyridamole (1-100 mu M) enhanced interleukin-1beta-induced nitrite production in a dose- and time-dependent manner. The mRNA expression of inducible NO synthase was up-regulated by dipyridamole (0.3-10 mu M) treatment in a dose-dependent manner. Both 8-bromo-guanosine 3',5'-cyclic monophosphate (8-bromo-cGMP) and dibutyryl adenosine 3',5'-cyclic monophosphate (db-cAMP) enhanced the nitrite production in the presence of interleukin-1beta. Dipyridamole up-regulated the effect of both 8-bromo-cGMP and db-cAMP on the interleukin-1beta-induced nitrite production. Dipyridamole increased the intracellular cAMP content in the presence of interleukin-1beta (10 ng/ml), but did not affect the intracellular cGMP content. 8R*,9S*,11S*-(-)-9-hydroxy-9-n-hexyloxy-8-methyl-2,3,9,10- tetrahydro-8,11-epoxy-1H,8H,11H-2,7b,11a-triazadibenzo-(a,g)-cy cloocta ++-(c,d,e)-trinden-1-one (KT 5720), a selective inhibitor of cAMP-dependent protein kinase, abolished the enhancement of interleukin-1beta-induced nitrite production by dipyridamole, whereas 8R*,9S*,11S*-(-)-9-methoxy-carbamyl-8-methyl-2,3,9,10-tetrahydro-8,11-ep oxy-1H,8H,11H-2,7b,11a-trizadibenzo-(a,g)-cyclo-octa-(c,d,e)-tr inden-1-one (KT 5823), an inhibitor of cGMP-dependent protein kinase, did not attenuate the enhancement. Furthermore, Rolipram and 4-(3-butoxy-4-methoxybenzyl)-2-imidazolidinone (Ro-20-1724), cAMP-specific phosphodiesterase type IV inhibitors, augmented the interleukin-1beta-induced nitrite production. We concluded that dipyridamole enhanced the interleukin-1beta-induced NO production via an increase in intracellular cAMP content in cultured rat vascular smooth muscle cells.

123I-BMIPP (beta-methyl-iodophenyl pentadecanoic acid) has shown unique properties for potential use in assessing myocardial metabolism. Previous basic and clinical studies demonstrated that the disturbances of myocardial metabolism precede the occurrence of myocardial perfusion abnormalities by using 201Tl in hypertrophic myocardium. The present study was therefore undertaken to determine whether or not 123I-BMIPP myocardial SPECT is useful in predicting the prognosis of hypertrophic cardiomyopathy (HCM) in 65 patients in 6 facilities. There were 33 patients with non-obstructive HCM, 12 with obstructive HCM, 12 with apical HCM and 8 with dilated-phase HCM. Fasted patients at rest received an intravenous injection of 111 MBq of 123I-BMIPP. Twenty to thirty minutes later, myocardial SPECT was carried out. The BMIPP severity score (BMIPP SS) was evaluated semiquantitatively by using representative short axial SPECT images. We followed up the incidence of cardiac events for a mean period of 3.0 +/- 0.6 years. Cardiac events occurred in 13 patients. Of these, 11 developed heart failure and 6 died (4 from heart failure and 2 from sudden death). The BMIPP SS in the dilated-phase HCM was significantly lower than that for the nonsurvivors. The BMIPP SS was particularly high in patients with fatal heart failure. Furthermore, there was a close negative correlation between the BMIPP SS and percent fractional shortening measured by echocardiography (r = -0.49). Finally, the mortality over the three years increased according to the extent of the BMIPP SS. In conclusion, these results indicate that BMIPP SS is useful in evaluating the severity of HCM. We conclude that 123I-BMIPP is a valuable metabolic tracer in predicting the outcome of HCM.

This is the first multi-hospital epidemiological study to elucidate the prevalence and characteristics of urinary incontinence in elderly inpatients throughout Japan. Of the 2586 subjects to whom questionnaires were issued, 1563 (60.4%) (65 to 102 years old, 598 men, 965 women) were suitable for the study. A total of 817 patients were hospitalized in geriatric hospitals; that is, geriatric facilities under the regulation of the Department of Health and Welfare. All patients were evaluated by medical doctors for the following items: age, sex, duration of hospitalization, activities of daily living, medical diagnosis, presence or absence of urinary incontinence, type of urinary incontinence, and therapy for urinary incontinence. The prevalence of urinary incontinence in patients under 70, 70-79, 80-89, and over 90 years old was 59.3%, 67.7%, 79.8%, and 82.2%, respectively. Overall, 1142 patients (72.0%) suffered from urinary incontinence. Cerebrovascular disease was the major cause of admission to hospital in patients with urinary incontinence (37.0%). The most frequent type of urinary incontinence was functional urinary incontinence in patients who were mentally and/or physically unable to go to the bathroom without aid (21.5%). Specifically, 38.1% of patients in geriatric hospitals were diagnosed as having functional urinary incontinence, in contrast to only 3.9% of patients in non-geriatric units. In patients with dementia, 88.7% were incontinent, whereas in patients without dementia, the prevalence of urinary incontinence was much lower (51.5%, p < 0.001). Another predisposing factor for urinary incontinence was urinary tract infection. The prevalence of urinary incontinence in patients with and without urinary tract infection was 87.8% and 59.5%, respectively (p < 0.001). Almost all patients with poor activities of daily living (who were bedridden) suffered from urinary incontinence (98.5%). On the other hand, urinary incontinence was not so frequent in patients who could walk (26.9%). Pad (42.8%) and indwelling bladder catheter (18.3%) were the major means of management of incontinence, whereas behavioral therapy (4.9%) and surgery (0.5%) were not common. These results suggest that elderly patients with treatable urinary incontinence do not receive adequate therapy in Japan.

To investigate the role of kinins in augmentation of insulin sensitivity by angiotensin converting enzyme inhibitor (ACEI), the effects of ACEI (delapril) on the insulin resistance in fructose-fed rats (FFR) were evaluated with or without the administration of bradykinin receptor antagonist (Hoe 140). Male Sprague-Dawley rats were fed on fructose rich chow (FFR) or standard chow (control) for 4 weeks and treated with 10 mg/kg/day of delapril with or without Hoe 140 (0.5 mg/kg/day) for an additional 2 weeks. Steady state plasma glucose (SSPG) and steady state plasma insulin (SSPI) were determined while the rats were conscious. Insulin (2.5 mU/kg/min) and glucose (8 mg/kg/min) were simultaneously infused to determine insulin sensitivity in each group. Mean blood pressure (MBP), SSPG and SSPI were significantly higher in FFR than in control, and were significantly lower in the FFR+delapril than in FFR+vehicle. There were no difference in MBP, SSPG and SSPI between FFR+delapril+vehicle and FFR+delapril+Hoe 140. We concluded that the main mechanisms of improving the insulin sensitivity by ACEI may not be the enhancement of kinins but the suppression of angiotensin II in FFR.

Objectives: This study examined whether stimulation of adenosine receptors before ischemia enhances myocardial resistance to stunning in vivo., Background: We previously demonstrated the attenuation of myocardial stunning by ischemic preconditioning through adenosine receptor activation in rabbits., Methods: 1) To confirm the efficacy of an intravenous infusion of adenosine to stimulate adenosine receptors in the heart, we assessed the effect of an adenosine infusion on the inotropic response to an isoproterenol challenge. 2) Myocardial stunning was induced by 10 min of coronary occlusion and reperfusion. The regional thickening fraction was monitored by an epicardial Doppler sensor. Rabbits were pretreated with either no drug (control group), adenosine, 8-phenyltheophylline or a combination of 8-phenyltheophylline plus adenosine., Results: An intravenous infusion of adenosine at 0.15 mg/kg body weight per min attenuated by 50% the elevation of left ventricular dP/dtmax by isoproterenol (0.075 microgram/kg per min). The same dose of adenosine infused for 15 min before ischemia significantly improved the postischemic recovery of the thickening fraction, and the thickening fraction at 30 min reperfusion was 76.8 +/- 3.3% (mean +/- SE) of the baseline value, which was significantly higher than the control value (42.9 +/- 4.5%). The relation between thickening fraction and systolic left ventricular pressure after reperfusion was shifted toward higher thickening fraction by adenosine. This beneficial effect of adenosine was not detected in rabbits given 8-phenyltheophylline before adenosine, and 8-phenyltheophylline-treated rabbits showed a time course of thickening fraction similar to that in the control group., Conclusions: An intravenous infusion of adenosine is capable of protecting rabbit hearts against stunning through adenosine receptor activation.