- Resistant Hypertension
- Diabtetic Kidney Disease
- Electrolyte Disorders
Director, Stanford Pre-Renal Initiative, NIH NIDDK R25 (2020 - Present)
Member, Stanford Diabetes Research Center (2017 - Present)
Director, Stanford Hypertension Center (2015 - Present)
Director, Renal Physiology, Pre-Clinical Curriculum (2012 - 2022)
Honors & Awards
Fellow, American Society of Nephrology (2003)
Mentored Clinical Scientist Award (K08), NIH/NIDDK (2005-2010)
Teaching Awardee, Halie T. Debas Academy of Medical Educators, UCSF (2007)
Shaul G. Massry Young Investigator's Award, National Kidney Foundation (2008)
Carl W. Gottschalk Research Grant, American Society of Nephrology (2010-2012)
Faculty Mentor Award, Stanford Biodesign Program (2012)
Henry J Kaiser Family Foundation Award for Excellence in Preclinical Teaching, Stanford University School of Medicine (2012)
Fellow, American Heart Association (2017)
Outstanding Lecture / Presentation, Stanford University School of Medicine (2017)
Member, American Society of Clinical Investigation (2022)
Boards, Advisory Committees, Professional Organizations
Biosciences Research Advisory Group, American Society of Nephrology (2014 - 2016)
Vice-Chair, Kidney in Cardiovascular Disease Council, American Heart Association (2016 - 2018)
Member, Hypertension Council, American Heart Association (2016 - Present)
Chair, Kidney in Cardiovascular Disease Council, American Heart Association (2018 - 2020)
Board Certification: American Board of Internal Medicine, Internal Medicine (2020)
Medical Education: University of California San Diego School of Medicine (1998) CA
Board Certification: American Board of Internal Medicine, Nephrology (2020)
Fellowship: UCSF Dept of Nephrology (2005) CA
Residency: Harbor UCLA Internal Medicine Residency (2001) CA
Board Certification, American Society of Hypertension, Clinical Hypertension (2015)
Fellowship, University of California San Francisco, Nephrology (2005)
Residency, Harbor-UCLA Medical Center, Internal Medicine (2001)
M.D., Univ of California San Diego, Medicine (1998)
B.S., Univ of California Berkeley, Electrical Engineering (1994)
Current Research and Scholarly Interests
Dr. Bhalla received his training in molecular biology at UC San Francisco. His postdoctoral work centered on the regulation of aldosterone-mediated sodium transport in health and disease. In his laboratory he uses both in vitro and in vivo approaches for several projects related to the role of the kidney in health, diabetes, and hypertension.
(1) Diabetic kidney disease is costly and consequential. Diabetic kidney disease is the most common form of chronic kidney disease in the world, yet no curative therapy is available. Studies of the susceptibility of diabetic kidney disease led to the discovery of differential regulation of endothelial-specific molecule-1, Esm-1 (endocan) in susceptible strains of mice. Esm-1 is a secreted proteoglycan that is enriched in glomerular endothelium and inhibits LFA-1 : ICAM-1 interaction and decreases infiltration in glomeruli in the setting of diabetes and other inflammatory diseases. Ongoing rescue and deletion experiments explore the role of Esm-1 in diabetes and diabetic kidney disease. We also study the regulation of Esm-1 transcription and protein stability.
(2) Investigation of the mechanisms of hypertension in the setting of obesity and insulin resistance using renal tubular epithelial insulin receptor deletion challenged the role of insulin in the hypertension of obesity, insulin resistance, and the metabolic syndrome. These studies also shed light on the role of insulin in control of glucose reabsorption via SGLT2. Ongoing studies focus on molecular mechanisms of insulin-regulated SGLT2 and its contrast with insulin resistant pathways in other cell types and tissues.
(3) An unexpected finding of aberrant regulation of potassium transport in obesity and insulin resistance has led to another project exploring the role of obesity and insulin in potassium transport in the cortical collecting duct.
(4) A major regulator of sodium reabsorption, Clcnkb, is mutated in humans with Barrter's syndrome, Type 3. However, surprisingly little is known about the regulation of this channel in health and disease. Ongoing experiments include the study of post-translational regulation of Clcnkb surface expression and activity using in vitro and in vivo approaches.
(5) Inhibition of sodium reabsorption using diuretics is a mainstay of therapy for hypertension and edema-forming states. Study on the consequences of diuretic therapy using tubular morphometry and single cell approaches have led to additional work on mechanisms of tubular remodeling in vivo.
Independent Studies (7)
- Directed Reading in Medicine
MED 299 (Aut, Win, Spr, Sum)
- Early Clinical Experience in Medicine
MED 280 (Aut, Win, Spr, Sum)
- Graduate Research
MED 399 (Aut, Win, Spr, Sum)
- Medical Scholars Research
MED 370 (Aut, Win, Spr, Sum)
- Out-of-Department Graduate Research
BIO 300X (Win)
- Out-of-Department Undergraduate Research
BIO 199X (Aut, Win, Spr, Sum)
- Undergraduate Research
MED 199 (Aut, Win, Spr, Sum)
- Directed Reading in Medicine
- Prior Year Courses
Graduate and Fellowship Programs
Describing Natural History and Exploring Risk Factors for Kidney Function Decline in Persons With CKD of Uncertain Etiology in Sri Lanka.
Kidney international reports
2023; 8 (7): 1430-1438
Chronic kidney disease of uncertain etiology (CKDu) is a leading cause of death of adults in Sri Lanka's dry region.We initiated the Kidney Progression Project (KiPP) to prospectively follow 292 persons with Chronic Kidney Disease Epidemiology Collaboration estimated glomerular filtration rate (eGFR) 20 to 60 ml/min per 1.73 m2 living in a CKDu endemic area. Using data from 3-year follow-up, we assessed kidney function decline (>30% from baseline eGFR), and the composite outcome of >30% eGFR decline, eGFR <15 ml/min or death, and explored the association of the 2 outcomes with baseline demographic, residential, and clinical parameters accounting for baseline eGFR.Median eGFR at enrollment was 28 ml/min among 71 women; 30 ml/min among 221 men; 91% to 99% had trace or no proteinuria during follow-up. At enrollment, median serum sodium, uric acid, and potassium were 143 mmol/l, 6.3 mg/dl, 4.5 meq/l, respectively among women; and 143 mmol/l, 6.9 mg/dl, 4.3 meq/l among men. Mean slope of eGFR decline was -0.5 (SD 4.9) ml/min/yr. In exploratory analyses, men with greater years of education and those living in northern region of the study area experienced lower likelihood of disease progression (hazard ratios [HR] 0.87 [0.77-0.98] per additional year and 0.33 [0.12-0.89] for northern versus other subregions, respectively). There was a suggestion that men drinking well water had higher likelihood and men living further away from reservoirs had lower likelihood of >30% decline in eGFR (HR 2.07 [0.95-4.49] for drinking well water versus not, and HR 0.58 [0.32-1.05] per kilometer distance, respectively).The overall rate of kidney function decline was slow in this CKDu cohort, similar to other nonalbuminuric CKD, and event rates were similar among men and women. Further etiologic investigations could focus on specific residence locale and water use.
View details for DOI 10.1016/j.ekir.2023.04.010
View details for PubMedID 37441476
View details for PubMedCentralID PMC10334401
Underdiagnosis of Primary Aldosteronism: A Review of Screening and Detection.
American journal of kidney diseases : the official journal of the National Kidney Foundation
A clinical condition may be missed due to its higher-than-recognized prevalence or inadequate diagnostic screening. Primary aldosteronism suffers from both of these factors and thus, is woefully underdiagnosed as a cause of hypertension and end-organ damage. Furthermore, screening tests should be strongly considered in diseases that pose significant morbidity or mortality if left untreated; have a high prevalence; and have treatments that lead to improvement or cure. In this review we present evidence on each of these points. We outline studies that estimate prevalence of primary aldosteronism in different at-risk populations and how the recognition has changed over time. We also evaluate myriad studies of screening rates for primary aldosteronism and what factors do and do not influence current screening practices. We discuss the ideal conditions for screening, the performance of the aldosterone-to-renin ratio in different populations that use plasma renin activity or direct renin concentration, and the steps for diagnostic work-up of primary aldosteronism. Finally, we conclude with potential strategies to implement higher rates of screening and diagnosis of this common, consequential, and treatable disease.
View details for DOI 10.1053/j.ajkd.2023.01.447
View details for PubMedID 36965825
- Rare Presentation of Paroxysmal High B-Pee. Hypertension (Dallas, Tex. : 1979) 2023
Endothelial Cell-Specific Molecule-1 Inhibits Albuminuria in Diabetic Mice.
2022; 3 (12): 2059-2076
Background: Diabetic kidney disease (DKD) is the most common cause of kidney failure in the world, and novel predictive biomarkers and molecular mechanisms of disease are needed. Endothelial cell-specific molecule-1 (Esm-1) is a secreted proteoglycan that attenuates inflammation. We previously identified that a glomerular deficiency of Esm-1 associates with more pronounced albuminuria and glomerular inflammation in DKD-susceptible relative to DKD-resistant mice, but its contribution to DKD remains unexplored.Methods: Using hydrodynamic tail-vein injection, we overexpress Esm-1 in DKD-susceptible DBA/2 mice and delete Esm-1 in DKD-resistant C57BL/6 mice to study the contribution of Esm-1 to DKD. We analyze clinical indices of DKD, leukocyte infiltration, podocytopenia, and extracellular matrix production. We also study transcriptomic changes to assess potential mechanisms of Esm-1 in glomeruli.Results: In DKD-susceptible mice, Esm-1 inversely correlates with albuminuria and glomerular leukocyte infiltration. We show that overexpression of Esm-1 reduces albuminuria and diabetes-induced podocyte injury, independent of changes in leukocyte infiltration. Using a complementary approach, we find that constitutive deletion of Esm-1 in DKD-resistant mice modestly increases the degree of diabetes-induced albuminuria versus wild-type controls. By glomerular RNAseq, we identify that Esm-1 attenuates expression of kidney disease-promoting and interferon (IFN)-related genes, including Ackr2 and Cxcl11.Conclusions: We demonstrate that, in DKD-susceptible mice, Esm-1 protects against diabetes-induced albuminuria and podocytopathy, possibly through select IFN signaling. Companion studies in patients with diabetes suggest a role of Esm-1 in human DKD.
View details for DOI 10.34067/KID.0001712022
View details for PubMedID 36591362
- Proximal Tubular Secretion: A New Way to Assess for Kidney Dysfunction? Kidney international reports 2022; 7 (12): 2558-2559
A COL4A4-G394S Variant and Impaired Collagen IV Trimerization in a Patient with Mild Alport Syndrome
2022; 3 (11): 1899-1908
Missense variants in COL4A genes are often found in patients with an Alport syndrome-like presentation, but their pathogenicity is not always clear. We encountered a woman with microscopic hematuria and proteinuria at 33 years of age with a diagnosis of thin basement membrane disease who was approaching end stage kidney disease at 59 years of age. We hypothesized that this patient's kidney disease was within the spectrum of Alport syndrome.We used histologic, genetic, and biochemical approaches to investigate the mechanisms of kidney disease. By immunofluorescence, we investigated collagen IV chain composition of the glomerular basement membrane (GBM). We employed targeted sequencing to search for pathogenic variants in COL4A and other relevant genes. We utilized N- and C-terminal split NanoLuciferase assays to determine the effect of a novel COL4A4 variant of uncertain significance (VUS) on collagen IV heterotrimer formation in vitro. We transfected COL4A4 expression constructs with split NanoLuciferase fragment-fused COL4A3 and COL4A5 constructs into human embryonic kidney 293T cells. To assay for α3α4α5(IV) heterotrimer formation and secretion, we measured luminescence in cell lysates and culture supernatants from transfected cells.Immunostaining suggested that the collagen α3α4α5(IV) network was present throughout the patient's GBMs. DNA sequencing revealed a novel homozygous VUS: COL4A4 c.1180G>A (p. Gly394Ser). In the C-terminal split luciferase-based α3α4α5(IV) heterotrimer formation assays, luminescence levels for G394S were comparable to WT, but in the N-terminal tag assays, the extracellular luminescence levels for G394S were decreased by approximately 50% compared with WT.Our cell-based assay provides a platform to test COL4 VUS and shows that G394S impairs assembly of the α3α4α5(IV) N-terminus and subsequent trimer secretion. These data suggest that the COL4A4-G394S variant is pathogenic and causes an atypical mild form of autosomal recessive Alport syndrome.
View details for DOI 10.34067/KID.0005472022
View details for Web of Science ID 000889087100013
View details for PubMedID 36514391
View details for PubMedCentralID PMC9717634
Novel CLC-Kb pore mutation associated with defective glycosylation and renal tubulopathy
OXFORD UNIV PRESS INC. 2022: 1026-1027
View details for Web of Science ID 000878249700143
Revascularization for Renovascular Disease: A Scientific Statement From the American Heart Association
2022; 79 (8): E128-E143
Renovascular disease is a major causal factor for secondary hypertension and renal ischemic disease. However, several prospective, randomized trials for atherosclerotic disease failed to demonstrate that renal revascularization is more effective than medical therapy for most patients. These results have greatly reduced the generalized diagnostic workup and use of renal revascularization. Most guidelines and review articles emphasize the limited average improvement and fail to identify those clinical populations that do benefit from revascularization. On the basis of the clinical experience of hypertension centers, specialists have continued selective revascularization, albeit without a summary statement by a major, multidisciplinary, national organization that identifies specific populations that may benefit. In this scientific statement for health care professionals and the public-at-large, we review the strengths and weaknesses of randomized trials in revascularization and highlight (1) when referral for consideration of diagnostic workup and therapy may be warranted, (2) the evidence/rationale for these selective scenarios, (3) interventional and surgical techniques for effective revascularization, and (4) areas of research with unmet need.
View details for DOI 10.1161/HYP.0000000000000217
View details for Web of Science ID 000823310100003
View details for PubMedID 35708012
- Self-limited Hypertension Due to Kidney Infarction. Kidney medicine 2022; 4 (5): 100454
- Changing the Trajectory of Heart Failure and Kidney Disease. Clinical journal of the American Society of Nephrology : CJASN 2022
- Hypothesis: Accessory renal arteries may be an overlooked cause of renin-dependent hypertension. Journal of human hypertension 2021
- Feasibility Of An Asynchronous, Semi-Automated Remote Patient Monitoring Blood Pressure Management System LIPPINCOTT WILLIAMS & WILKINS. 2021
Canagliflozin, serum magnesium and cardiovascular outcomes-Analysis from the CANVAS Program.
Endocrinology, diabetes & metabolism
2021; 4 (3): e00247
Background: Patients with type 2 diabetes (T2D) are predisposed to derangements in serum Magnesium (Mg), which may have implications for cardiometabolic events and outcomes. In clinical trials, participants with T2D randomized to sodium-glucose co-transporter 2 (SGLT2) inhibitors have shown mild to moderate increases in serum Mg from baseline levels. This post hoc analysis assesses the relation between serum Mg with cardiovascular outcomes in 10,140 participants of the Canagliflozin Cardiovascular Assessment Study (CANVAS) Program.Methods: We evaluated the association of baseline serum Mg with the primary composite end point of death from cardiovascular causes, non-fatal myocardial infarction, and non-fatal stroke, and tested whether this association is modified by baseline serum Mg. Using mediation analysis, we determined whether change in serum Mg post-randomization mediates the beneficial effect of canagliflozin on cardiovascular outcomes.Results: Mean serum Mg levels at baseline were 0.77±0.09mmol/L in both canagliflozin group and placebo groups. The canagliflozin group experienced an average increase in serum Mg by 0.07mmol/L (95% CI, 0.065-0.072mmol/L; p<.001) for the duration of the trial. We found no association between baseline serum Mg levels and the primary composite end point, and no evidence of effect modification by baseline Mg levels. Change in serum Mg post-randomization was not a mediator of the effects of canagliflozin on cardiovascular outcomes.Conclusions: In participants of the CANVAS Program, baseline and post-randomization serum Mg levels are not associated with cardiovascular outcomes.
View details for DOI 10.1002/edm2.247
View details for PubMedID 34277971
Masking by hypokalemia-primary aldosteronism with undetectable aldosterone.
Clinical kidney journal
2021; 14 (4): 1269–71
Primary aldosteronism is the most common cause of secondary hypertension; however, the dynamic regulation of aldosterone by potassium is less well studied and current diagnostic recommendations are imprecise. We describe a young man who presented with resistant hypertension and severe hypokalemia. The workup initially revealed undetectable aldosterone despite acute potassium repletion. Chronic potassium supplementation eventually uncovered hyperaldosteronism. In situ genetic studies revealed a gain-of-function KCNJ5 mutation within an aldosterone-producing adenoma that was clinically responsive to changes in extracellular potassium. We highlight a unique presentation of Conn's syndrome and discuss the implications for the molecular mechanisms of potassium regulation of aldosterone.
View details for DOI 10.1093/ckj/sfaa150
View details for PubMedID 33841871
Aldosterone sensitivity: an opportunity for investigation into the pathogenesis of hypertension.
American journal of physiology. Renal physiology
Aldosterone sensitivity is defined as an outcome variable for a given circulating level of aldosterone. In basic and translational studies, this has been measured in differential tissue responses, e.g. lower urine sodium and higher urine potassium, as an index of renal response; and in clinical studies has been measured in differential blood pressure. This concept of aldosterone sensitivity disrupts the conventional wisdom of the renin-angiotensin-aldosterone system and has the potential to uncover novel mechanisms of hypertension. We review basic and translational science studies that uncovered differential renal responses to aldosterone and connect this earlier work to more recent observational and randomized trials that have demonstrated differential blood pressure for a given level of aldosterone in healthy and hypertensive subjects. Black race and age are associated with higher aldosterone sensitivity and blood pressure. We also discuss gaps in the field and how future basic and clinical studies can inform mechanisms of differential sensitivity.
View details for DOI 10.1152/ajprenal.00415.2020
View details for PubMedID 33491565
- A historical perspective on ACE2 in the COVID-19 era. Journal of human hypertension 2020
- Uncontrolled Hypertension in an Elderly Man on Multiple Antihypertensive Drugs. Hypertension (Dallas, Tex. : 1979) 2020: HYPERTENSIONAHA12015310
- SGLT2 inhibitors: Diabetic kidney disease and beyond. American journal of physiology. Renal physiology 2020
- Sound Science before Quick Judgement Regarding RAS Blockade in COVID-19. Clinical journal of the American Society of Nephrology : CJASN 2020
Urinary Albumin, Sodium, and Potassium and Cardiovascular Outcomes in the UK Biobank: Observational and Mendelian Randomization Analyses.
Hypertension (Dallas, Tex. : 1979)
Urinary biomarkers are associated with cardiovascular disease, but the nature of these associations is not well understood. We performed multivariable-adjusted regression models to assess associations of random spot measurements of the urine sodium-potassium ratio (UNa/UK) and urine albumin adjusted for creatinine with cardiovascular risk factors, cardiovascular disease, and type 2 diabetes mellitus (T2D) in 478 311 participants of the UK Biobank. Further, we assessed the causal relationships of these kidney biomarkers, used as proxies for kidney function, with cardiovascular outcomes using the 2-sample Mendelian randomization approach. In observational analyses, UNa/UK showed significant inverse associations with atrial fibrillation, coronary artery disease, ischemic stroke, lipid-lowering medication, and T2D. In contrast, urine albumin adjusted for creatinine showed significant positive associations with atrial fibrillation, coronary artery disease, heart failure, hemorrhagic stroke, lipid-lowering medication, and T2D. We found a positive association between UNa/UK and albumin with blood pressure (BP), as well as with adiposity-related measures. After correcting for potential horizontal pleiotropy, we found evidence of causal associations of UNa/UK and albumin with BP (beta systolic BP ≥2.63; beta diastolic BP ≥0.85 SD increase in BP per SD change in UNa/UK and urine albumin adjusted for creatinine; P≤0.04), and of albumin with T2D (odds ratio=1.33 per SD change in albumin, P=0.02). Our comprehensive study of urinary biomarkers performed using state-of-the-art analyses of causality mirror and extend findings from randomized interventional trials which have established UNa/UK as a risk factor for hypertension. In addition, we detect a causal feedback loop between albumin and hypertension, and our finding of a bidirectional causal association between albumin and T2D reflects the well-known nephropathy in T2D.
View details for DOI 10.1161/HYPERTENSIONAHA.119.14028
View details for PubMedID 32008434
Screening Rates for Primary Aldosteronism in Resistant Hypertension: A Cohort Study.
Hypertension (Dallas, Tex. : 1979)
Resistant hypertension is associated with higher rates of cardiovascular disease, kidney disease, and death than primary hypertension. Although clinical practice guidelines recommend screening for primary aldosteronism among persons with resistant hypertension, rates of screening are unknown. We identified 145 670 persons with hypertension and excluded persons with congestive heart failure or advanced chronic kidney disease. Among this cohort, we studied 4660 persons ages 18 to <90 from the years 2008 to 2014 with resistant hypertension and available laboratory tests within the following 24 months. The screening rate for primary aldosteronism in persons with resistant hypertension was 2.1%. Screened persons were younger (55.9±13.3 versus 65.5±11.6 years; P<0.0001) and had higher systolic (145.1±24.3 versus 139.6±20.5 mm Hg; P=0.04) and diastolic blood pressure (81.8±13.6 versus 74.4±13.8 mm Hg; P<0.0001), lower rates of coronary artery disease (5.2% versus 14.2%; P=0.01), and lower serum potassium concentrations (3.9±0.6 versus 4.1±0.5 mmol/L; P=0.04) than unscreened persons. Screened persons had significantly higher rates of prescription for calcium channel blockers, mixed alpha/beta-adrenergic receptor antagonists, sympatholytics, and vasodilators, and lower rates of prescription for loop, thiazide, and thiazide-type diuretics. The prescription of mineralocorticoid receptor antagonists or other potassium-sparing diuretics was not significantly different between groups (P=0.20). In conclusion, only 2.1% of eligible persons received a screening test within 2 years of meeting criteria for resistant hypertension. Low rates of screening were not due to the prescription of antihypertensive medications that may potentially interfere with interpretation of the screening test. Efforts to highlight guideline-recommended screening and targeted therapy are warranted.
View details for DOI 10.1161/HYPERTENSIONAHA.119.14359
View details for PubMedID 32008436
Testing for Primary Aldosteronism and Mineralocorticoid Receptor Antagonist Use Among U.S. Veterans : A Retrospective Cohort Study.
Annals of internal medicine
Primary aldosteronism is a common cause of treatment-resistant hypertension. However, evidence from local health systems suggests low rates of testing for primary aldosteronism.To evaluate testing rates for primary aldosteronism and evidence-based hypertension management in patients with treatment-resistant hypertension.Retrospective cohort study.U.S. Veterans Health Administration.Veterans with apparent treatment-resistant hypertension (n = 269 010) from 2000 to 2017, defined as either 2 blood pressures (BPs) of at least 140 mm Hg (systolic) or 90 mm Hg (diastolic) at least 1 month apart during use of 3 antihypertensive agents (including a diuretic), or hypertension requiring 4 antihypertensive classes.Rates of primary aldosteronism testing (plasma aldosterone-renin) and the association of testing with evidence-based treatment using a mineralocorticoid receptor antagonist (MRA) and with longitudinal systolic BP.4277 (1.6%) patients who were tested for primary aldosteronism were identified. An index visit with a nephrologist (hazard ratio [HR], 2.05 [95% CI, 1.66 to 2.52]) or an endocrinologist (HR, 2.48 [CI, 1.69 to 3.63]) was associated with a higher likelihood of testing compared with primary care. Testing was associated with a 4-fold higher likelihood of initiating MRA therapy (HR, 4.10 [CI, 3.68 to 4.55]) and with better BP control over time.Predominantly male cohort, retrospective design, susceptibility of office BPs to misclassification, and lack of confirmatory testing for primary aldosteronism.In a nationally distributed cohort of veterans with apparent treatment-resistant hypertension, testing for primary aldosteronism was rare and was associated with higher rates of evidence-based treatment with MRAs and better longitudinal BP control. The findings reinforce prior observations of low adherence to guideline-recommended practices in smaller health systems and underscore the urgent need for improved management of patients with treatment-resistant hypertension.National Institutes of Health.
View details for DOI 10.7326/M20-4873
View details for PubMedID 33370170
- Kidney Case Conference Series: How We Manage Hypertension in a Patient with a Recent Stroke. Clinical journal of the American Society of Nephrology : CJASN 2020
- 2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2019; 12 (11): e000057
Current Status of Angiotensin Receptor Blocker Recalls.
Hypertension (Dallas, Tex. : 1979)
Losartan was the ninth most prescribed drug in the United States in 2016, and several other angiotensin-II receptor blockers (ARBs) are widely prescribed. Since July 2018, >2 dozen specific ARB products have been recalled owing to the presence of potentially carcinogenic nitrosamine impurities in selected lots. As is the case with all U.S. drug recalls, the ARB recalls have been voluntary on the part of the companies involved. In April 2019, the Food and Drug Administration categorized marketed ARB products with respect to nitrosamine impurities: (1) not present, (2) to be determined with no prior lots removed from the market (TBD), or (3) to be determined in the context of prior lots having been removed from the market (TBD*). The data were structured as hundreds of rows of products. Owing to the complexity of these data, more than a year into the recalls, it remains difficult for clinicians to understand which ARB products are free of impurities.
View details for DOI 10.1161/HYPERTENSIONAHA.119.13955
View details for PubMedID 31630573
Intercalated Cells of the Kidney Collecting Duct in Kidney Physiology.
Seminars in nephrology
2019; 39 (4): 353–67
The epithelium of the kidney collecting duct (CD) is composed mainly of two different types of cells with distinct and complementary functions. CD principal cells traditionally have been considered to have a major role in Na+ and water regulation, while intercalated cells (ICs) were thought to largely modulate acid-base homeostasis. In recent years, our understanding of IC function has improved significantly owing to new research findings. Thus, we now have a new model for CD transport that integrates mechanisms of salt and water reabsorption, K+ homeostasis, and acid-base status between principal cells and ICs. There are three main types of ICs (type A, type B, and non-A, non-B), which first appear in the late distal convoluted tubule or in the connecting segment in a species-dependent manner. ICs can be detected in CD from cortex to the initial part of the inner medulla, although some transport proteins that are key components of ICs also are present in medullary CD, cells considered inner medullary. Of the three types of ICs, each has a distinct morphology and expresses different complements of membrane transport proteins that translate into very different functions in homeostasis and contributions to CD luminal pro-urine composition. This review includes recent discoveries in IC intracellular and paracrine signaling that contributes to acid-base regulation as well as Na+, Cl-, K+, and Ca2+ homeostasis. Thus, these new findings highlight the potential role of ICs as targets for potential hypertension treatments.
View details for DOI 10.1016/j.semnephrol.2019.04.005
View details for PubMedID 31300091
Comparison of routine and automated office blood pressure measurement.
Blood pressure monitoring
OBJECTIVES: From April to October 2018, we implemented a blood pressure measurement quality improvement project at our Hypertension Center. We aimed to compare blood pressure measured using routine, non-standardized office blood pressure and Systolic Blood Pressure Intervention Trial-like automated office blood pressure protocols.METHODS: In 202 consecutive patients, we measured blood pressure using routine clinic methods and an automated office blood pressure protocol (5min of rest followed by three blood pressure measurements at 1-min intervals).RESULTS: The mean routine blood pressure was 145.6/76.4 mmHg and the mean automated office blood pressure was 135.3/70.1 mmHg. The mean paired difference in blood pressure was 10.3/6.3 mmHg, and Bland-Altman plots demonstrated wide limits of agreement. Using the systolic blood pressure goal of 130 mmHg, 26.9% of the patients not at goal by routine blood pressure were at goal by automated office blood pressure.CONCLUSIONS: Misclassifications of patient blood pressure control status and the wide variability between routine blood pressure and automated office blood pressure support the wider clinical implementation of automated office blood pressure to improve standardization, minimize incorrect blood pressure measurement and avoid over-treatment.
View details for DOI 10.1097/MBP.0000000000000392
View details for PubMedID 31116155
- Hypertension Hot Potato - Anatomy of the Angiotensin-Receptor Blocker Recalls NEW ENGLAND JOURNAL OF MEDICINE 2019; 380 (17): 1589–91
Cardiorenal Syndrome: Classification, Pathophysiology, Diagnosis, and Treatment Strategies A Scientific Statement From the American Heart Association
2019; 139 (16): E840–E878
Cardiorenal syndrome encompasses a spectrum of disorders involving both the heart and kidneys in which acute or chronic dysfunction in 1 organ may induce acute or chronic dysfunction in the other organ. It represents the confluence of heart-kidney interactions across several interfaces. These include the hemodynamic cross-talk between the failing heart and the response of the kidneys and vice versa, as well as alterations in neurohormonal markers and inflammatory molecular signatures characteristic of its clinical phenotypes. The mission of this scientific statement is to describe the epidemiology and pathogenesis of cardiorenal syndrome in the context of the continuously evolving nature of its clinicopathological description over the past decade. It also describes diagnostic and therapeutic strategies applicable to cardiorenal syndrome, summarizes cardiac-kidney interactions in special populations such as patients with diabetes mellitus and kidney transplant recipients, and emphasizes the role of palliative care in patients with cardiorenal syndrome. Finally, it outlines the need for a cardiorenal education track that will guide future cardiorenal trials and integrate the clinical and research needs of this important field in the future.
View details for DOI 10.1161/CIR.0000000000000664
View details for Web of Science ID 000469321500001
View details for PubMedID 30852913
Prospective Biopsy-Based Study of Chronic Kidney Disease of Unknown Etiology in Sri Lanka.
Clinical journal of the American Society of Nephrology : CJASN
BACKGROUND AND OBJECTIVES: A kidney disease of unknown cause is common in Sri Lanka's lowland (dry) region. Detailed clinical characterizations of patients with biopsy-proven disease are limited, and there is no current consensus on criteria for a noninvasive diagnosis.DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We designed a prospective study in a major Sri Lankan hospital servicing endemic areas to ascertain pathologic and clinical characteristics of and assess risk factors for primary tubulointerstitial kidney disease. We used logistic regression to determine whether common clinical characteristics could be used to predict the presence of primary tubulointerstitial kidney disease on kidney biopsy.RESULTS: From 600 new patients presenting to a tertiary nephrology clinic over the course of 1 year, 87 underwent kidney biopsy, and 43 (49%) had a biopsy diagnosis of primary tubulointerstitial kidney disease. On detailed biopsy review, 13 (30%) had evidence of moderate to severe active kidney disease, and six (15%) had evidence of moderate to severe chronic tubulointerstitial kidney disease. Patients with tubulointerstitial kidney disease were exclusively born in endemic provinces; 91% spent a majority of their lifespan there. They were more likely men and farmers (risk ratio, 2.0; 95% confidence interval, 1.2 to 2.9), and they were more likely to have used tobacco (risk ratio, 1.7; 95% confidence interval, 1.0 to 2.3) and well water (risk ratio, 1.5; 95% confidence interval, 1.1 to 2.0). Three clinical characteristics-age, urine dipstick for protein, and serum albumin-could predict likelihood of tubulointerstitial kidney disease on biopsy (model sensitivity of 79% and specificity of 84%). Patients referred for kidney biopsy despite comorbid diabetes or hypertension did not experience lower odds of tubulointerstitial kidney disease.CONCLUSIONS: A primary tubulointerstitial kidney disease occurs commonly in specific regions of Sri Lanka with characteristic environmental and lifestyle exposures.PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_01_18_CJASNPodcast_19_02_.mp3.
View details for PubMedID 30659059
Celebrating 40 Years of Accomplishments.
Hypertension (Dallas, Tex. : 1979)
2019; 73 (1): 3–6
View details for PubMedID 30571572
AMPK phosphorylation of the β1Pix exchange factor regulates the assembly and function of an ENaC inhibitory complex in kidney epithelial cells.
American journal of physiology. Renal physiology
The metabolic sensor AMP-activated protein kinase (AMPK) inhibits the epithelial Na+ channel (ENaC), a key regulator of salt reabsorption by the kidney and thus total body volume and blood pressure. Recent studies suggest that AMPK promotes the association of the PAK-interacting exchange factor β1Pix, 14-3-3 proteins, and the ubiquitin ligase Nedd4-2 into a complex that inhibits ENaC by enhancing Nedd4-2 binding to ENaC and ENaC degradation. Functional β1Pix is required for ENaC inhibition by AMPK and promotes Nedd4-2 phosphorylation and stability in mouse kidney cortical collecting duct (CCD) cells. Here, we report that AMPK directly phosphorylates β1Pix in vitro. Among several AMPK phosphorylation sites on β1Pix detected by mass spectrometry (MS), Ser-71 was validated as functionally significant. Compared to wild-type β1Pix, overexpression of a phosphorylation-deficient β1Pix-S71A mutant attenuated ENaC inhibition and the AMPK-activated interaction of both β1Pix and Nedd4-2 to 14-3-3 proteins in CCD cells. Similarly, overexpression of a β1Pix-Δ602-611 deletion-tract mutant unable to bind 14-3-3 proteins decreased the interaction between Nedd4-2 and 14-3-3 proteins, suggesting that 14-3-3 binding to β1Pix is critical for the formation of a β1Pix/Nedd4-2/14-3-3 complex. With expression of a general peptide inhibitor of 14-3-3-target protein interactions (R18), binding of both β1Pix and Nedd4-2 to 14-3-3 proteins were reduced, and AMPK-dependent ENaC inhibition was also attenuated. Altogether, our results demonstrate the importance of AMPK-mediated phosphorylation of β1Pix at Ser-71, which promotes 14-3-3 interactions with β1Pix and Nedd4-2 to form a tripartite ENaC inhibitory complex, in the mechanism of ENaC regulation by AMPK.
View details for DOI 10.1152/ajprenal.00592.2018
View details for PubMedID 31566435
- Celebrating 40 Years of Accomplishments HYPERTENSION 2019; 73 (1): 3–6
- Epidemiology, molecular, and genetic methodologies to evaluate causes of CKDu around the world: report of the Working Group from the ISN International Consortium of Collaborators on CKDu. Kidney international 2019; 96 (6): 1254–60
Renal tubule insulin receptor modestly promotes elevated blood pressure and markedly stimulates glucose reabsorption.
2018; 3 (16)
Although the cause of hypertension among individuals with obesity and insulin resistance is unknown, increased plasma insulin, acting in the kidney to increase sodium reabsorption, has been proposed as a potential mechanism. Insulin may also stimulate glucose uptake, but the contributions of tubular insulin signaling to sodium or glucose transport in the setting of insulin resistance is unknown. To directly study the role of insulin signaling in the kidney, we generated inducible renal tubule-specific insulin receptor-KO mice and used high-fat feeding and mineralocorticoids to model obesity and insulin resistance. Insulin receptor deletion did not alter blood pressure or sodium excretion in mice on a high-fat diet alone, but it mildly attenuated the increase in blood pressure with mineralocorticoid supplementation. Under these conditions, KO mice developed profound glucosuria. Insulin receptor deletion significantly reduced SGLT2 expression and increased urinary glucose excretion and urine flow. These data demonstrate a direct role for insulin receptor-stimulated sodium and glucose transport and a functional interaction of insulin signaling with mineralocorticoids in vivo. These studies uncover a potential mechanistic link between preserved insulin sensitivity and renal glucose handling in obesity and insulin resistance.
View details for PubMedID 30135311
Age-Related Blood Pressure Sensitivity to Aldosterone in Blacks and Whites
2018; 72 (1): 247–52
Aldosterone sensitivity, defined as the magnitude of the association of plasma aldosterone concentration with blood pressure (BP), seems to be a function of plasma volume. It increases as plasma renin activity decreases, and it is more significant in blacks but less so in whites. Age is a strong determinant of BP, and an increase in aldosterone sensitivity could contribute to the increase in BP. In the present study, we tested the hypothesis that aldosterone sensitivity increases with age. We used observational data collected from normotensive blacks and whites enrolled in a prospective cohort study. They were studied as children (248 blacks/357 whites) and again as young adults (74 blacks/125 whites) over an age range of 7 to 39 years. A varying-coefficient regression analysis was used to explore the influences of aldosterone on systolic BP. After controlling for body mass index, race, and sex, both plasma renin activity and plasma aldosterone concentration were lower in blacks, and their levels declined with age (P<0.001). In blacks, plasma aldosterone concentration decreased 0.25 ng/dL per year; in whites, plasma aldosterone concentration decreased 0.18 per year. Aldosterone's effect on BP, characterized by a smooth function of age, intensified as age increased, especially in blacks (P<0.01), suggesting an increased aldosterone sensitivity with age. In comparison to blacks, age-related changes in aldosterone sensitivity in whites were not statistically significant. These findings extend the rationale for targeting aldosterone in the treatment of hypertension, especially in blacks.
View details for PubMedID 29785962
Improved protocols for the study of urinary electrolyte excretion and blood pressure in rodents: use of gel food and stepwise changes in diet composition.
American journal of physiology. Renal physiology
Many experimental protocols in rodents require the comparison of groups that are fed different diets. Changes in dietary electrolyte and/or fat content can influence food intake, which can potentially introduce bias or confound the results. Unpalatable diets slow growth or cause weight loss, which is exacerbated by housing the animals in individual metabolic cages or by surgery. For balance studies in mice, small body weight and food intake, and low urinary flow can amplify these challenges. Powder food can be administered as a gel with the addition of a desired amount of water, electrolytes, drugs (if any), and a small amount of agar. We describe here how the use of gel food, to vary water, Na, K, and fat content can reduce weight loss and improve reproducibility of intake, urinary excretion, and blood pressure in rodents. In addition, mild food restriction reduces the inter-individual variability and inter-group differences in food intake and associated variables, thus, improving the statistical power of the experiment. Finally, we also demonstrate the advantages of using gel food for weight-based drug dosing. These protocols can improve the accuracy and reproducibility of experimental data where dietary manipulations are needed, and are especially advisable in rodent studies related to water balance, obesity and blood pressure.
View details for PubMedID 29357416
A Novel High-Resolution Magnetic Resonance Imaging Protocol Detects Aldosterone-Producing Adenomas in Patients with Negative Computed Tomography.
American journal of hypertension
View details for PubMedID 29648568
- Explaining the Coincidence Rule for Estimating Respiratory Compensation in Metabolic Acid-Base Disorders ANNALS OF INTERNAL MEDICINE 2017; 166 (8): 610-610
Molecular Mechanisms of Sodium-Sensitive Hypertension in the Metabolic Syndrome.
Current hypertension reports
2017; 19 (8): 60
We review the known mechanisms of sodium-sensitive hypertension in the metabolic syndrome with a focus on preclinical models, differences between these models, and methodological limitations. We also identify future directions for a better understanding and treatment of this common condition.Rigorous methodologies to measure blood pressure in preclinical models may clarify some of the inconsistencies in the literature. Renal, neural, hormonal, and cardiovascular systems are dysregulated and contribute to elevated blood pressure. Local renin-angiotensin systems enhance systemic hormone signaling to increase blood pressure. Since the original description of metabolic syndrome, investigators from many fields have contributed to an increasingly complex and mechanistic understanding of this common condition. These systems integrate to regulate sodium transport in the kidney leading to hypertension and enhanced sodium sensitivity. An array of non-uniform preclinical models are used and support clinical studies to inform which models are pathophysiologically relevant for further mechanistic studies to guide targeted therapy.
View details for PubMedID 28676941
Insights from direct renal insulin infusion: a new hammer for an age-old nail.
American journal of physiology. Renal physiology
View details for PubMedID 29141941
Murine glomerular transcriptome links endothelial cell-specific molecule-1 deficiency with susceptibility to diabetic nephropathy.
2017; 12 (9): e0185250
Diabetic nephropathy (DN) is the leading cause of kidney disease; however, there are no early biomarkers and no cure. Thus, there is a large unmet need to predict which individuals will develop nephropathy and to understand the molecular mechanisms that govern this susceptibility. We compared the glomerular transcriptome from mice with distinct susceptibilities to DN at four weeks after induction of diabetes, but before histologic injury, and identified differential regulation of genes that modulate inflammation. From these genes, we identified endothelial cell specific molecule-1 (Esm-1), as a glomerular-enriched determinant of resistance to DN. Glomerular Esm-1 mRNA and protein were lower in DN-susceptible, DBA/2, compared to DN-resistant, C57BL/6, mice. We demonstrated higher Esm-1 secretion from primary glomerular cultures of diabetic mice, and high glucose was sufficient to increase Esm-1 mRNA and protein secretion in both strains of mice. However, induction was significantly attenuated in DN-susceptible mice. Urine Esm-1 was also significantly higher only in DN-resistant mice. Moreover, using intravital microscopy and a biomimetic microfluidic assay, we showed that Esm-1 inhibited rolling and transmigration in a dose-dependent manner. For the first time we have uncovered glomerular-derived Esm-1 as a potential non-invasive biomarker of DN. Esm-1 inversely correlates with disease susceptibility and inhibits leukocyte infiltration, a critical factor in protecting the kidney from DN.
View details for PubMedID 28934365
Pemetrexed-Induced Nephrogenic Diabetes Insipidus
AMERICAN JOURNAL OF KIDNEY DISEASES
2016; 68 (4): 628-632
Pemetrexed is an approved antimetabolite agent, now widely used for treating locally advanced or metastatic nonsquamous non-small cell lung cancer. Although no electrolyte abnormalities are described in the prescribing information for this drug, several case reports have noted nephrogenic diabetes insipidus with associated acute kidney injury. We present a case of nephrogenic diabetes insipidus without severely reduced kidney function and propose a mechanism for the isolated finding. Severe hypernatremia can lead to encephalopathy and osmotic demyelination, and our report highlights the importance of careful monitoring of electrolytes and kidney function in patients with lung cancer receiving pemetrexed.
View details for DOI 10.1053/j.ajkd.2016.04.016
View details for Web of Science ID 000383892200024
View details for PubMedID 27241854
- New perspective of ClC-Kb/2 Cl- channel physiology in the distal renal tubule AMERICAN JOURNAL OF PHYSIOLOGY-RENAL PHYSIOLOGY 2016; 310 (10): P923-P930
Na+-sensitive elevation in blood pressure is ENaC independent in diet-induced obesity and insulin resistance
AMERICAN JOURNAL OF PHYSIOLOGY-RENAL PHYSIOLOGY
2016; 310 (9): F812-F820
The majority of patients with obesity, insulin resistance, and metabolic syndrome have hypertension, but the mechanisms of hypertension are poorly understood. In these patients, impaired sodium excretion is critical for the genesis of Na(+)-sensitive hypertension, and prior studies have proposed a role for the epithelial Na(+) channel (ENaC) in this syndrome. We characterized high fat-fed mice as a model in which to study the contribution of ENaC-mediated Na(+) reabsorption in obesity and insulin resistance. High fat-fed mice demonstrated impaired Na(+) excretion and elevated blood pressure, which was significantly higher on a high-Na(+) diet compared with low fat-fed control mice. However, high fat-fed mice had no increase in ENaC activity as measured by Na(+) transport across microperfused cortical collecting ducts, electrolyte excretion, or blood pressure. In addition, we found no difference in endogenous urinary aldosterone excretion between groups on a normal or high-Na(+) diet. High fat-fed mice provide a model of metabolic syndrome, recapitulating obesity, insulin resistance, impaired natriuresis, and a Na(+)-sensitive elevation in blood pressure. Surprisingly, in contrast to previous studies, our data demonstrate that high fat feeding of mice impairs natriuresis and produces elevated blood pressure that is independent of ENaC activity and likely caused by increased Na(+) reabsorption upstream of the aldosterone-sensitive distal nephron.
View details for DOI 10.1152/ajprenal.00265.2015
View details for Web of Science ID 000375115700003
View details for PubMedID 26841823
- Regulation of the Water Channel Aquaporin-2 via 14-3-3 theta and-zeta JOURNAL OF BIOLOGICAL CHEMISTRY 2016; 291 (5): 2469-2484
Regulation of the Water Channel Aquaporin-2 via 14-3-3? and -?.
journal of biological chemistry
2016; 291 (5): 2469-2484
The 14-3-3 family of proteins are multifunctional proteins that interact with many of their cellular targets in a phosphorylation-dependent manner. Here, we determined that 14-3-3 proteins interact with phosphorylated forms of the water channel aquaporin-2 (AQP2) and modulate its function. With the exception of σ, all 14-3-3 isoforms were abundantly expressed in mouse kidney and mouse kidney collecting duct cells (mpkCCD14). Long-term treatment of mpkCCD14 cells with the type 2 vasopressin receptor agonist dDAVP increased mRNA and protein levels of AQP2 alongside 14-3-3β and -ζ, whereas levels of 14-3-3η and -θ were decreased. Co-immunoprecipitation (co-IP) studies in mpkCCD14 cells uncovered an AQP2/14-3-3 interaction that was modulated by acute dDAVP treatment. Additional co-IP studies in HEK293 cells determined that AQP2 interacts selectively with 14-3-3ζ and -θ. Use of phosphatase inhibitors in mpkCCD14 cells, co-IP with phosphorylation deficient forms of AQP2 expressed in HEK293 cells, or surface plasmon resonance studies determined that the AQP2/14-3-3 interaction was modulated by phosphorylation of AQP2 at various sites in its carboxyl terminus, with Ser-256 phosphorylation critical for the interactions. shRNA-mediated knockdown of 14-3-3ζ in mpkCCD14 cells resulted in increased AQP2 ubiquitylation, decreased AQP2 protein half-life, and reduced AQP2 levels. In contrast, knockdown of 14-3-3θ resulted in increased AQP2 half-life and increased AQP2 levels. In conclusion, this study demonstrates phosphorylation-dependent interactions of AQP2 with 14-3-3θ and -ζ. These interactions play divergent roles in modulating AQP2 trafficking, phosphorylation, ubiquitylation, and degradation.
View details for DOI 10.1074/jbc.M115.691121
View details for PubMedID 26645691
View details for PubMedCentralID PMC4732228
- The missing link: studying the alternative TGF-ß pathway provides a unifying theory for different components of diabetic nephropathy. Diabetes 2015; 64 (6): 1898-1900
Harvest and primary culture of the murine aldosterone-sensitive distal nephron.
American journal of physiology. Renal physiology
2015; 308 (11): F1306-15
The aldosterone-sensitive distal nephron (ASDN) exhibits axial heterogeneity in structure and function from the distal convoluted tubule to the medullary collecting duct. Ion and water transport is primarily divided between the cortex and medulla of the ASDN, respectively. Transcellular transport in this segment is highly regulated in health and disease and is integrated across different cell types. We currently lack an inexpensive, high-yield, and tractable technique to harvest and culture cells for the study of gene expression and physiologic properties of mouse cortical ASDN. To address this need, we harvested tubules bound to Dolichos biflorus agglutinin (DBA) lectin-coated magnetic beads from kidney cortex and characterized these cell preparations. We determined that these cells are enriched for markers of distal convoluted tubule, connecting tubule, and cortical collecting duct, including principal and intercalated cells. In primary culture these cells develop polarized monolayers with high-resistance (1000-1500 Ω*cm(2)), and maintain expression and activity of key channels. These cells demonstrate an amiloride-sensitive short-circuit current that can be enhanced with aldosterone and maintain measurable potassium and anion secretion. Our method can be easily adopted to study the biology of the ASDN and to investigate phenotypic differences between wild-type and transgenic mouse models.
View details for DOI 10.1152/ajprenal.00668.2014
View details for PubMedID 25810438
- Is there a sweet spot for Nrf2 activation in the treatment of diabetic kidney disease? Diabetes 2014; 63 (9): 2904-2905
Racial/Ethnic differences in the prevalence of proteinuric and nonproteinuric diabetic kidney disease.
2013; 36 (5): 1215-1221
OBJECTIVE To examine racial/ethnic differences in the prevalence of diabetic kidney disease (DKD), with and without proteinuria, in an outpatient health care organization. RESEARCH DESIGN AND METHODS We examined electronic health records for 15,683 persons of non-Hispanic white (NHW), Asian (Asian Indian, Chinese, and Filipino), Hispanic, and non-Hispanic black (NHB) race/ethnicity with type 2 diabetes and no prior history of kidney disease from 2008 to 2010. We directly standardized age- and sex-adjusted prevalence rates of proteinuric DKD (proteinuria with or without low estimated glomerular filtration rate [eGFR]) or nonproteinuric DKD (low eGFR alone). We calculated sex-specific odds ratios of DKD in racial/ethnic minorities (relative to NHWs) after adjustment for traditional DKD risk factors. RESULTS Racial/ethnic minorities had higher rates of proteinuric DKD than NHWs (24.8-37.9 vs. 24.8%) and lower rates of nonproteinuric DKD (6.3-9.8 vs. 11.7%). On adjusted analyses, Chinese (odds ratio 1.39 for women and 1.56 for men), Filipinos (1.57 for women and 1.85 for men), Hispanics (1.46 for women and 1.34 for men), and NHBs (1.50 for women) exhibited significantly (P < 0.01) higher odds of proteinuric DKD than NHWs. Conversely, Chinese, Hispanic, and NHB women and Hispanic men had significantly lower odds of nonproteinuric DKD than NHWs. CONCLUSIONS We found novel racial/ethnic differences in DKD among patients with type 2 diabetes. Racial/ethnic minorities were more likely to have proteinuric DKD and less likely to have nonproteinuric DKD. Future research should examine diverse DKD-related outcomes by race/ethnicity to inform targeted prevention and treatment efforts and to explore the etiology of these differences.
View details for DOI 10.2337/dc12-0951
View details for PubMedID 23238659
- A transcriptional blueprint for human and murine diabetic kidney disease. Diabetes 2013; 62 (1): 31-33
Low-Level Lead Exposure and the Prevalence of Gout An Observational Study
ANNALS OF INTERNAL MEDICINE
2012; 157 (4): 233-?
Blood lead levels (BLLs) less than 1.21 µmol/L (<25 µg/dL) among adults are considered acceptable by current national standards. Lead toxicity can lead to gouty arthritis (gout), but whether the low lead exposure in the contemporary general population confers risk for gout is not known.To determine whether BLLs within the range currently considered acceptable are associated with gout.Population-based cross-sectional study.The National Health and Nutrition Examination Survey for 2005 through 2008.6153 civilians aged 40 years or older with an estimated glomerular filtration rate greater than 10 mL/min per 1.73 m2.Outcome variables were self-reported physician diagnosis of gout and serum urate level. Blood lead level was the principal exposure variable. Additional data collected were anthropometric measures, blood pressure, dietary purine intake, medication use, medical history, and serum creatinine concentration.The prevalence of gout was 6.05% (95% CI, 4.49% to 7.62%) among patients in the highest BLL quartile (mean, 0.19 µmol/L [3.95 µg/dL]) compared with 1.76% (CI, 1.10% to 2.42%) among those in the lowest quartile (mean, 0.04 µmol/L [0.89 µg/dL]). Each doubling of BLL was associated with an unadjusted odds ratio of 1.74 (CI, 1.47 to 2.05) for gout and 1.25 (CI, 1.12 to 1.40) for hyperuricemia. After adjustment for renal function, diabetes, diuretic use, hypertension, race, body mass index, income, and education level, the highest BLL quartile was associated with a 3.6-fold higher risk for gout and a 1.9-fold higher risk for hyperuricemia compared with the lowest quartile.Blood lead level does not necessarily reflect the total body lead burden.Blood lead levels in the range currently considered acceptable are associated with increased prevalence of gout and hyperuricemia.
View details for Web of Science ID 000307813200014
View details for PubMedID 22910934
Neural Precursor Cell-expressed Developmentally Down-regulated Protein 4-2 (Nedd4-2) Regulation by 14-3-3 Protein Binding at Canonical Serum and Glucocorticoid Kinase 1 (SGK1) Phosphorylation Sites
JOURNAL OF BIOLOGICAL CHEMISTRY
2011; 286 (43): 37830-37840
Regulation of epithelial Na(+) channel (ENaC)-mediated transport in the distal nephron is a critical determinant of blood pressure in humans. Aldosterone via serum and glucocorticoid kinase 1 (SGK1) stimulates ENaC by phosphorylation of the E3 ubiquitin ligase Nedd4-2, which induces interaction with 14-3-3 proteins. However, the mechanisms of SGK1- and 14-3-3-mediated regulation of Nedd4-2 are unclear. There are three canonical SGK1 target sites on Nedd4-2 that overlap phosphorylation-dependent 14-3-3 interaction motifs. Two of these are termed "minor," and one is termed "major," based on weak or strong binding to 14-3-3 proteins, respectively. By mass spectrometry, we found that aldosterone significantly stimulates phosphorylation of a minor, relative to the major, 14-3-3 binding site on Nedd4-2. Phosphorylation-deficient minor site Nedd4-2 mutants bound less 14-3-3 than did wild-type (WT) Nedd4-2, and minor site Nedd4-2 mutations were sufficient to inhibit SGK1 stimulation of ENaC cell surface expression. As measured by pulse-chase and cycloheximide chase assays, a major binding site Nedd4-2 mutant had a shorter cellular half-life than WT Nedd4-2, but this property was not dependent on binding to 14-3-3. Additionally, a dimerization-deficient 14-3-3ε mutant failed to bind Nedd4-2. We conclude that whereas phosphorylation at the Nedd4-2 major site is important for interaction with 14-3-3 dimers, minor site phosphorylation by SGK1 may be the relevant molecular switch that stabilizes Nedd4-2 interaction with 14-3-3 and thus promotes ENaC cell surface expression. We also propose that major site phosphorylation promotes cellular Nedd4-2 protein stability, which potentially represents a novel form of regulation for turnover of E3 ubiquitin ligases.
View details for DOI 10.1074/jbc.M111.293233
View details for Web of Science ID 000296542400077
View details for PubMedID 21900244
View details for PubMedCentralID PMC3199524
- In diabetic nephropathy, high doses of vitamin B decrease glomerular filtration rate and increase risk of the composite outcome of a vascular event or all-cause mortality compared with placebo. Evidence-based medicine 2011; 16 (1): 14-15
Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial
2010; 376 (9756): 1903-1909
Activation of renal sympathetic nerves is key to pathogenesis of essential hypertension. We aimed to assess effectiveness and safety of catheter-based renal denervation for reduction of blood pressure in patients with treatment-resistant hypertension.In this multicentre, prospective, randomised trial, patients who had a baseline systolic blood pressure of 160 mm Hg or more (≥150 mm Hg for patients with type 2 diabetes), despite taking three or more antihypertensive drugs, were randomly allocated in a one-to-one ratio to undergo renal denervation with previous treatment or to maintain previous treatment alone (control group) at 24 participating centres. Randomisation was done with sealed envelopes. Data analysers were not masked to treatment assignment. The primary effectiveness endpoint was change in seated office-based measurement of systolic blood pressure at 6 months. Primary analysis included all patients remaining in follow-up at 6 months. This trial is registered with ClinicalTrials.gov, number NCT00888433.106 (56%) of 190 patients screened for eligibility were randomly allocated to renal denervation (n=52) or control (n=54) groups between June 9, 2009, and Jan 15, 2010. 49 (94%) of 52 patients who underwent renal denervation and 51 (94%) of 54 controls were assessed for the primary endpoint at 6 months. Office-based blood pressure measurements in the renal denervation group reduced by 32/12 mm Hg (SD 23/11, baseline of 178/96 mm Hg, p<0·0001), whereas they did not differ from baseline in the control group (change of 1/0 mm Hg [21/10], baseline of 178/97 mm Hg, p=0·77 systolic and p=0·83 diastolic). Between-group differences in blood pressure at 6 months were 33/11 mm Hg (p<0·0001). At 6 months, 41 (84%) of 49 patients who underwent renal denervation had a reduction in systolic blood pressure of 10 mm Hg or more, compared with 18 (35%) of 51 controls (p<0·0001). We noted no serious procedure-related or device-related complications and occurrence of adverse events did not differ between groups; one patient who had renal denervation had possible progression of an underlying atherosclerotic lesion, but required no treatment.Catheter-based renal denervation can safely be used to substantially reduce blood pressure in treatment-resistant hypertensive patients.Ardian.
View details for DOI 10.1016/S0140-6736(10)62039-9
View details for Web of Science ID 000285439800031
View details for PubMedID 21093036
Phosphopeptide Screen Uncovers Novel Phosphorylation Sites of Nedd4-2 That Potentiate Its Inhibition of the Epithelial Na+ Channel
JOURNAL OF BIOLOGICAL CHEMISTRY
2010; 285 (28): 21671-21678
The E3 ubiquitin ligase Nedd4-2 regulates several ion transport proteins, including the epithelial Na(+) channel (ENaC). Nedd4-2 decreases apical membrane expression and activity of ENaC. Although it is subject to tight hormonal control, the mechanistic basis of Nedd4-2 regulation remains poorly understood. To characterize regulatory inputs to Nedd4-2 function, we screened for novel sites of Nedd4-2 phosphorylation using tandem mass spectrometry. Three of seven identified Xenopus Nedd4-2 Ser/Thr phosphorylation sites corresponded to previously identified target sites for SGK1, whereas four were novel, including Ser-293, which matched the consensus for a MAPK target sequence. Further in vitro and in vivo phosphorylation experiments revealed that Nedd4-2 serves as a target of JNK1, but not of p38 MAPK or ERK1/2. Additional rounds of tandem mass spectrometry identified two other phosphorylated residues within Nedd4-2, including Thr-899, which is present within the catalytic domain. Nedd4-2 with mutations at these sites had markedly inhibited JNK1-dependent phosphorylation, virtually no ENaC inhibitory activity, and significantly reduced ubiquitin ligase activity. These data identify phosphorylatable residues that activate Nedd4-2 and may work together with residues targeted by inhibitory kinases (e.g. SGK1 and protein kinase A) to govern Nedd4-2 regulation of epithelial ion transport.
View details for DOI 10.1074/jbc.M109.084731
View details for Web of Science ID 000279516100054
View details for PubMedID 20466724
View details for PubMedCentralID PMC2898378
Phosphopeptide Screen Uncovers JNK1 as a Potentiator of Nedd4-2-Mediated Epithelial Na plus Channel Inhibition
FEDERATION AMER SOC EXP BIOL. 2010
View details for Web of Science ID 000208675504492
Lead poisoning from an Ayurvedic herbal medicine in a patient with chronic kidney disease
NATURE REVIEWS NEPHROLOGY
2009; 5 (5): 297-300
A 60-year-old man with a history of diabetes and hypertension was referred to a nephrology clinic for investigation of his elevated serum creatinine level.Physical examination; laboratory investigations, including measurement of whole-blood lead level, body lead burden and urine albumin:creatinine ratio; history of lead exposure and use of herbal medical products; and renal ultrasonography.Stage 3 chronic kidney disease that was probably worsened by consumption of lead in the form of an Ayurvedic herbal remedy.Cessation of the herbal product, followed by lead-chelation therapy with calcium disodium ethylenediaminetetraacetic acid. The patient's whole-body lead burden and blood lead level decreased to acceptable levels and his serum creatinine value was within the normal range at final follow-up.
View details for DOI 10.1038/nrneph.2009.41
View details for Web of Science ID 000265854500012
View details for PubMedID 19384331
Melamine nephrotoxicity: an emerging epidemic in an era of globalization
2009; 75 (8): 774-779
Recent outbreaks of nephrolithiasis and acute kidney injury among children in China have been linked to ingestion of milk-based infant formula contaminated with melamine. These cases provide evidence in humans for the nephrotoxicity of melamine, which previously had been described only in animals. The consequences of this outbreak are already severe and will likely continue to worsen. Herein we summarize the global impact of the melamine milk contamination, the reemergence of melamine-tainted animal feed, and potential mechanisms of melamine nephrotoxicity. Large-scale epidemiologic studies are necessary to further characterize this disease and to assess its potential long-term sequelae. This epidemic of environmental kidney disease highlights the morbidity associated with adulterated food products available in today's global marketplace and reminds us of the unique vulnerability of the kidney to environmental insults. Melamine is the latest in a growing list of diverse potentially toxic compounds about which nephrologists and other health-care providers responsible for the diagnosis and management of kidney disease must now be aware.
View details for DOI 10.1038/ki.2009.16
View details for PubMedID 19212415
Mechanisms of ENaC regulation and clinical implications
JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY
2008; 19 (10): 1845-1854
The epithelial Na+ channel (ENaC) transports Na+ across tight epithelia, including the distal nephron. Different paradigms of ENaC regulation include extrinsic and intrinsic factors that affect the expression, single-channel properties, and intracellular trafficking of the channel. In particular, recent discoveries highlight new findings regarding proteolytic processing, ubiquitination, and recycling of the channel. Understanding the regulation of this channel is critical to the understanding of various clinical phenomena, including normal physiology and several diseases of kidney and lung epithelia, such as blood pressure (BP) control, edema, and airway fluid clearance. Significant progress has been achieved in this active field of research. Although ENaC is classically thought to be a mediator of BP and volume status through Na+ reabsorption in the distal nephron, several studies in animal models highlight important roles for ENaC in lung pathophysiology, including in cystic fibrosis. The purpose of this review is to highlight the various modes and mechanisms of ENaC regulation, with a focus on more recent studies and their clinical implications.
View details for DOI 10.1681/ASN.2008020225
View details for Web of Science ID 000259830900005
View details for PubMedID 18753254
NH2 terminus of serum and glucocorticoid-regulated kinase 1 binds to phosphoinositides and is essential for isoform-specific physiological functions
AMERICAN JOURNAL OF PHYSIOLOGY-RENAL PHYSIOLOGY
2007; 292 (6): F1741-F1750
Serum and glucocorticoid regulated kinase 1 (SGK1) has been identified as a key regulatory protein that controls a diverse set of cellular processes including sodium (Na(+)) homeostasis, osmoregulation, cell survival, and cell proliferation. Two other SGK isoforms, SGK2 and SGK3, have been identified, which differ most markedly from SGK1 in their NH(2)-terminal domains. We found that SGK1 and SGK3 are potent stimulators of epithelial Na(+) channel (ENaC)-dependent Na(+) transport, while SGK2, which has a short NH(2) terminus, is a weak stimulator of ENaC. Further characterization of the role of the SGK1 NH(2) terminus revealed that its deletion does not affect in vitro kinase activity but profoundly limits the ability of SGK1 either to stimulate ENaC-dependent Na(+) transport or inhibit Forkhead-dependent gene transcription. The NH(2) terminus of SGK1, which shares sequence homology with the phosphoinositide 3-phosphate [PI(3)P] binding domain of SGK3, binds phosphoinositides in protein lipid overlay assays, interacting specifically with PI(3)P, PI(4)P, and PI(5)P, but not with PI(3,4,5)P(3). Moreover, a point mutation that reduces phosphoinositide binding to the NH(2) terminus also reduces SGK1 effects on Na(+) transport and Forkhead activity. These data suggest that the NH(2) terminus, although not required for PI 3-kinase-dependent modulation of SGK1 catalytic activity, is required for multiple SGK1 functions, including stimulation of ENaC and inhibition of the proapoptotic Forkhead transcription factor. Together, these observations support the idea that the NH(2)-terminal domain acts downstream of PI 3-kinase-dependent activation to target the kinase to specific cellular compartments and/or substrates, possibly through its interactions with a subset of phosphoinositides.
View details for DOI 10.1152/ajprenal.00027.2007
View details for Web of Science ID 000247942000010
View details for PubMedID 17356130
Disinhibitory pathways for control of sodium transport: regulation of ENaC by SGK1 and GILZ
AMERICAN JOURNAL OF PHYSIOLOGY-RENAL PHYSIOLOGY
2006; 291 (4): F714-F721
Regulation of ENaC occurs at several levels. The principal hormonal regulator of ENaC, aldosterone, acts through the mineralocorticoid receptor to modulate ENaC-mediated sodium transport, and considerable attention has focused on defining the components of the early phase of this response. Two genes, SGK1 and GILZ, have now been implicated in this regulation. While the functional significance of SGK1 in mediating aldosterone effects is well established, new evidence has enhanced our understanding of the mechanisms of SGK1 action. In addition, recent work demonstrates a novel role for GILZ in the stimulation of ENaC-mediated sodium transport. Interestingly, both SGK1 and GILZ appear to negatively regulate tonic inhibition of ENaC and thus use disinhibition to propagate the rapid effects of aldosterone to increase sodium reabsorption in tight epithelia.
View details for DOI 10.1152/ajprenal.00061.2006
View details for Web of Science ID 000240313000002
View details for PubMedID 16720863
AMP-activated kinase inhibits the epithelial Na+ channel through functional regulation of the ubiquitin ligase Nedd4-2
JOURNAL OF BIOLOGICAL CHEMISTRY
2006; 281 (36): 26159-26169
We recently found that the metabolic sensor AMP-activated kinase (AMPK) inhibits the epithelial Na+ channel (ENaC) through decreased plasma membrane ENaC expression, an effect requiring the presence of a binding motif in the cytoplasmic tail of the beta-ENaC subunit for the ubiquitin ligase Nedd4-2. To further examine the role of Nedd4-2 in the regulation of ENaC by AMPK, we studied the effects of AMPK activation on ENaC currents in Xenopus oocytes co-expressing ENaC and wild-type (WT) or mutant forms of Nedd4-2. ENaC inhibition by AMPK was preserved in oocytes expressing WT Nedd4-2 but blocked in oocytes expressing either a dominant-negative (DN) or constitutively active (CA) Nedd4-2 mutant, suggesting that AMPK-dependent modulation of Nedd4-2 function is involved. Similar experiments utilizing WT or mutant forms of the serum- and glucocorticoid-regulated kinase (SGK1), modulators of protein kinase A (PKA), or extracellular-regulated kinase (ERK) did not affect ENaC inhibition by AMPK, suggesting that these pathways known to modulate the Nedd4-2-ENaC interaction are not responsible. AMPK-dependent phosphorylation of Nedd4-2 expressed in HEK-293 cells occurred both in vitro and in vivo, suggesting a potential mechanism for modulation of Nedd4-2 and thus cellular ENaC activity. Moreover, cellular AMPK activation significantly enhanced the interaction of the beta-ENaC subunit with Nedd4-2, as measured by co-immunoprecipitation assays in HEK-293 cells. In summary, these results suggest a novel mechanism for ENaC regulation in which AMPK promotes ENaC-Nedd4-2 interaction, thereby inhibiting ENaC by increasing Nedd4-2-dependent ENaC retrieval from the plasma membrane. AMPK-dependent ENaC inhibition may limit cellular Na+ loading under conditions of metabolic stress when AMPK becomes activated.
View details for DOI 10.1074/jbc.M606045200
View details for Web of Science ID 000240249500032
View details for PubMedID 16844684
Serum- and glucocorticoid-regulated kinase 1 regulates ubiquitin ligase neural precursor cell-expressed, developmentally down-regulated protein 4-2 by inducing interaction with 14-3-3
2005; 19 (12): 3073-3084
Serum- and glucocorticoid-regulated kinase 1 (SGK1) is an aldosterone-regulated early response gene product that regulates the activity of several ion transport proteins, most notably that of the epithelial sodium channel (ENaC). Recent evidence has established that SGK1 phosphorylates and inhibits Nedd4-2 (neural precursor cell-expressed, developmentally down-regulated protein 4-2), a ubiquitin ligase that decreases cell surface expression of the channel and possibly stimulates its degradation. The mechanistic basis for this SGK1-induced Nedd4-2 inhibition is currently unknown. In this study we show that SGK1-mediated phosphorylation of Nedd4-2 induces its interaction with members of the 14-3-3 family of regulatory proteins. Through functional characterization of Nedd4-2-mutant proteins, we demonstrate that this interaction is required for SGK1-mediated inhibition of Nedd4-2. The concerted action of SGK1 and 14-3-3 appears to disrupt Nedd4-2-mediated ubiquitination of ENaC, thus providing a mechanism by which SGK1 modulates the ENaC-mediated Na(+) current. Finally, the expression pattern of 14-3-3 is also consistent with a functional role in distal nephron Na(+) transport. These results demonstrate a novel, physiologically significant role for 14-3-3 proteins in modulating ubiquitin ligase-dependent pathways in the control of epithelial ion transport.
View details for DOI 10.1210/me.2005-0193
View details for Web of Science ID 000233460500015
View details for PubMedID 16099816
SGK1: A rapid aldosterone-induced regulator of renal sodium reabsorption
2005; 20: 134-139
Recently, substantial progress has been made in understanding the mechanisms by which aldosterone rapidly stimulates sodium transport in the distal nephron and other tight epithelia. Serum- and glucocorticoid-regulated kinase 1 (SGK1) has been identified as an important mediator of this process. Its physiological relevance has been revealed through heterologous expression in cultured cells and generation of SGK1 knockout mice.
View details for DOI 10.1152/physiol.00053.2004
View details for Web of Science ID 000227958500008
View details for PubMedID 15772302
Recurrent and de novo diabetic nephropathy in renal allografts
2003; 75 (1): 66-71
Histologic findings of diabetic nephropathy (DN) are observed in allografts of patients with pretransplant (PreTx) diabetes mellitus (DM) and in patients who develop DM posttransplant (PostTx). Patients with allograft biopsies (Bx) were retrospectively studied to determine the incidence of recurrent and de novo DN and to ascertain what, if any, risk factors predispose to histologic DN in either patient population.From the renal transplant services at four hospitals from 1992 to 2000, the authors identified all patients with PreTxDM and PostTxDM (n=81). Those with renal biopsies performed >/=18 months PostTx were classified according to the presence or absence of histologic DN (Bx-positive, n=23; Bx-negative, n=35). Patients were then subdivided into four categories-recurrent DN (n=16), de novo DN (n=7), no recurrent DN (n=27), and no de novo DN (n=8)-for analyses.Among these 58 patients, 74.1% had PreTx and 25.9% had PostTx diabetes. Of those with histologic DN, 69.6% were recurrent DN and 30.4% were de novo DN, making de novo DN at least as likely to develop as recurrent DN. After the onset of diabetes in the de novo population, the time to development of histologic DN was similar in the recurrent and the de novo patients (6.68+/-3.86 years vs. 5.90+/-3.13 years, P=0.66) and more rapid than previously reported. Apart from a more frequent family history of hypertension in patients with allograft DN compared with those without allograft DN, known risk factors for the development of native DN did not significantly differ among patients in the four cohorts. Proposed risk factors related to transplantation did not correlate with the development of recurrent or de novo DN.Among patients with histologic DN, de novo DN occurred at least as frequently as recurrent DN, and the time to onset of histologically apparent DN was more rapid than previously reported. Neither the usual clinical predictors of DN nor clinical variables related to transplantation clearly distinguished the group with DN from the group without it, potentially implicating novel mechanisms in its pathogenesis.
View details for DOI 10.1097/01.TP.0000040870.94999.87
View details for Web of Science ID 000180617800012
View details for PubMedID 12544873