No / Contrast agents are used to enhance imaging examinations, however in magnetic resonance imaging (MRI) there is an association with nephrogenic systemic fibrosis (NSF). The risk is small, but elevated in patients with impaired renal function and screening of patients is advised prior to administration. This study examines adherence of UK hospitals to guidance on the use of gadolinium based contrast agents (GBCA) in MRI. This was a prospective study utilising an electronic survey. The sample comprised NHS Trusts in the UK (n = 174). An invitation was sent to all MRI lead radiographers including a link to the survey. 17.6% indicated they had no written protocol for the GBCA administration within radiology. 41.2% check blood test results for all patients undergoing a contrast MRI, whereas 45.6% only check those patients with known renal dysfunction or are high-risk. Comorbidities which categorised patients as high-risk included diabetes, cardiac or vascular disease and age, however the cut off varied from 65 to 75 years old. Six sites indicated point-of-care (POC) creatinine testing would be carried out where bloods were unavailable, a further 12 had considered POC testing and dismissed it as an adjunct to the patient pathway, the most commonly cited reason being the cost. Within the UK there is no consistent approach to renal function assessment prior to GBCA administration despite international guidance. POC testing may have a role to play, but a lack of evaluation in radiology has led to concerns that it may constrain capacity and increase costs.

Le diabète insipide néphrogénique (DIN) autosomal peut être causé par les mutations du gène codant pour le canal à eau aquaporine-2 (AQP2). Un modèle couramment utilisé pour l’étude des protéines membranaires telle l’AQP2 est l’expression hétérologue dans les ovocytes de Xenopus laevis. Malheureusement, les techniques déjà existantes de purification de membranes plasmiques sont soit trop longues, trop difficiles ou demandent trop de matériel, ne permettent pas l’analyse adéquate du ciblage des formes sauvage comme mutantes, un élément crucial de ce type d’étude. Nous avons donc dans un premier temps mis au point une technique rapide et efficace de purification de membranes plasmiques qui combine la digestion partielle de la membrane vitelline, sa polymérisation à la membrane plasmique suivi de centrifugations à basse vitesse pour récolter les membranes purifiées. Nous avons utilisé cette technique dans l’étude de deux nouveaux cas familiaux de patients hétérozygotes possédant les mutations V24A et R187C dans un cas et K228E et R187C dans le second cas. Pour chaque mutation, nous avons analysé autant les éléments de fonctionnalité que les paramètres d’expression des protéines mutantes. Les expériences de perméabilité membranaire démontrent que les ovocytes exprimant AQP2-V24A (Pf = 16.3 ± 3.5 x 10-4 cm/s, 10 ng) et AQP2- K228E (Pf = 19.9 ± 7.0 x 10-4 cm/s, 10 ng) ont des activités similaires à celle exprimant la forme native (Pf = 14.4 ± 5.5 x 10-4 cm/s, 1 ng), tandis que AQP2- R187C (Pf = 2.6 ± 0.6 x 10-4 cm/s, 10 ng) ne semble avoir aucune activité comme ce qui est observé chez les ovocytes non-injectés (Pf = 2.8 ± 1.0 x 10-4 cm/s). Les études de co-expression ont démontré un effet d’additivité lorsque AQP2-V24A et -K228E sont injectées avec la forme native et un effet s’apparentant à la dominance négative lorsque AQP2-R187C est injecté avec la forme native, avec AQP2-V24A ou avec –K228E. Les résultats obtenus par immunobuvardage représente bien ce qui a été démontré précédemment, on remarque la présence des mutations K228E, V24A et la forme sauvage à la membrane plasmique, contrairement à la mutation R187C. Cependant, lorsque les mutations sont exprimées dans des cellules mIMCD-3, il n’y a qu’une faible expression à la membrane de la forme –K228E et une absence totale des formes –V24A et –R187C à la membrane plasmique, contrairement à la forme native. Les résultats de nos études démontrent que tout dépendant du système d’expression les formes –K228E et –V24A peuvent être utiles dans l’étude des problèmes d’adressage à la membrane à l’aide de chaperonne chimique. De plus, la forme –R187C démontre des difficultés d’adressage qui devront être étudiées afin de mieux comprendre la synthèse des formes natives. / The autosomal nephrogenic diabetes insipidus (NDI) is caused by mutations of the gene coding for the water channel aquaporine-2 (AQP2). An oftenly used model for the study of membrane proteins such as AQP2 is the heterogenous expression in Xenopus laevis oocytes. Unfortunately, the existing techniques of plasma membranes purification are either too long, too difficult or require too much material, which does not allow adequate analysis of targeting of the native and mutants forms, which is crucial for this type of study. We developed a fast and effective plasma membrane purification technique which combines partial digestion of the vitellin membrane, its polymerization with the plasma membrane followed by a serie of low speed centrifugations to collect the purified membranes. We used this technique to study of two new family cases of heterozygote patients carrying the V24A and R187C mutations in a case and K228E and R187C in the second case. For each mutation, we analyzed the functionality and the parameters of expression of the mutant proteins. The membrane permeability experiments show that the oocytes expressing AQP2- V24A (Pf = 16.3 ± 3.5 x 10-4 cm/s, 10 ng) and AQP2-K228E (Pf = 19.9 ± 7.0 x 10-4 cm/s, 10 ng) have similar activities to the oocytes expressing the native form (Pf = 14.4 ± 5.5 x 10-4 cm/s, 1 ng), while AQP2-R187C (Pf = 2.6 ± 0.6 x 10-4 cm/s, 10 ng) doesn’t seem to have any activity like the un-injected oocytes (Pf = 2.8 ± 1.0 x 10-4 cm/s). The coexpression studies showed an additive effect when AQP2-V24A and -K228E are injected with the native form and an effect being associated with negative dominance when AQP2-R187C was injected with AQP2-V24A, -K228E and the native form. Western blot results confirmed what was observed in the functionality studies. However, when the mutations were expressed in mIMCD-3 cells, there was a slight expression of the K228E mutation to the plasma membrane and a total absence of the mutations –V24A and R187C at the plasma membrane. The results of our studies showed that depending on the expression system the mutations –K228E and -V24A can be used in targeting studies using chemical chaperones.

Le diabète insipide néphrogénique (DIN) autosomal peut être causé par les mutations du gène codant pour le canal à eau aquaporine-2 (AQP2). Un modèle couramment utilisé pour l’étude des protéines membranaires telle l’AQP2 est l’expression hétérologue dans les ovocytes de Xenopus laevis. Malheureusement, les techniques déjà existantes de purification de membranes plasmiques sont soit trop longues, trop difficiles ou demandent trop de matériel, ne permettent pas l’analyse adéquate du ciblage des formes sauvage comme mutantes, un élément crucial de ce type d’étude. Nous avons donc dans un premier temps mis au point une technique rapide et efficace de purification de membranes plasmiques qui combine la digestion partielle de la membrane vitelline, sa polymérisation à la membrane plasmique suivi de centrifugations à basse vitesse pour récolter les membranes purifiées. Nous avons utilisé cette technique dans l’étude de deux nouveaux cas familiaux de patients hétérozygotes possédant les mutations V24A et R187C dans un cas et K228E et R187C dans le second cas. Pour chaque mutation, nous avons analysé autant les éléments de fonctionnalité que les paramètres d’expression des protéines mutantes. Les expériences de perméabilité membranaire démontrent que les ovocytes exprimant AQP2-V24A (Pf = 16.3 ± 3.5 x 10-4 cm/s, 10 ng) et AQP2- K228E (Pf = 19.9 ± 7.0 x 10-4 cm/s, 10 ng) ont des activités similaires à celle exprimant la forme native (Pf = 14.4 ± 5.5 x 10-4 cm/s, 1 ng), tandis que AQP2- R187C (Pf = 2.6 ± 0.6 x 10-4 cm/s, 10 ng) ne semble avoir aucune activité comme ce qui est observé chez les ovocytes non-injectés (Pf = 2.8 ± 1.0 x 10-4 cm/s). Les études de co-expression ont démontré un effet d’additivité lorsque AQP2-V24A et -K228E sont injectées avec la forme native et un effet s’apparentant à la dominance négative lorsque AQP2-R187C est injecté avec la forme native, avec AQP2-V24A ou avec –K228E. Les résultats obtenus par immunobuvardage représente bien ce qui a été démontré précédemment, on remarque la présence des mutations K228E, V24A et la forme sauvage à la membrane plasmique, contrairement à la mutation R187C. Cependant, lorsque les mutations sont exprimées dans des cellules mIMCD-3, il n’y a qu’une faible expression à la membrane de la forme –K228E et une absence totale des formes –V24A et –R187C à la membrane plasmique, contrairement à la forme native. Les résultats de nos études démontrent que tout dépendant du système d’expression les formes –K228E et –V24A peuvent être utiles dans l’étude des problèmes d’adressage à la membrane à l’aide de chaperonne chimique. De plus, la forme –R187C démontre des difficultés d’adressage qui devront être étudiées afin de mieux comprendre la synthèse des formes natives. / The autosomal nephrogenic diabetes insipidus (NDI) is caused by mutations of the gene coding for the water channel aquaporine-2 (AQP2). An oftenly used model for the study of membrane proteins such as AQP2 is the heterogenous expression in Xenopus laevis oocytes. Unfortunately, the existing techniques of plasma membranes purification are either too long, too difficult or require too much material, which does not allow adequate analysis of targeting of the native and mutants forms, which is crucial for this type of study. We developed a fast and effective plasma membrane purification technique which combines partial digestion of the vitellin membrane, its polymerization with the plasma membrane followed by a serie of low speed centrifugations to collect the purified membranes. We used this technique to study of two new family cases of heterozygote patients carrying the V24A and R187C mutations in a case and K228E and R187C in the second case. For each mutation, we analyzed the functionality and the parameters of expression of the mutant proteins. The membrane permeability experiments show that the oocytes expressing AQP2- V24A (Pf = 16.3 ± 3.5 x 10-4 cm/s, 10 ng) and AQP2-K228E (Pf = 19.9 ± 7.0 x 10-4 cm/s, 10 ng) have similar activities to the oocytes expressing the native form (Pf = 14.4 ± 5.5 x 10-4 cm/s, 1 ng), while AQP2-R187C (Pf = 2.6 ± 0.6 x 10-4 cm/s, 10 ng) doesn’t seem to have any activity like the un-injected oocytes (Pf = 2.8 ± 1.0 x 10-4 cm/s). The coexpression studies showed an additive effect when AQP2-V24A and -K228E are injected with the native form and an effect being associated with negative dominance when AQP2-R187C was injected with AQP2-V24A, -K228E and the native form. Western blot results confirmed what was observed in the functionality studies. However, when the mutations were expressed in mIMCD-3 cells, there was a slight expression of the K228E mutation to the plasma membrane and a total absence of the mutations –V24A and R187C at the plasma membrane. The results of our studies showed that depending on the expression system the mutations –K228E and -V24A can be used in targeting studies using chemical chaperones.

L’aquaporine-2 (AQP2) est le canal responsable de la réabsorption finale d’eau au niveau du tubule collecteur du rein. À la base, contenue dans des vésicules internes, l’AQP2 est acheminée à la membrane apicale des cellules principales du tubule collecteur suite à une stimulation par l’hormone antidiurétique (ADH). L’incapacité à accomplir cette fonction entraîne le diabète insipide néphrogénique (DIN), une maladie caractérisée par l’inhabileté du rein à concentrer l’urine, entraînant une production de volumes urinaires élevés. Alors que les mutations récessives génèrent des protéines mal structurées et incapables de former des tétramères, les mutations dominantes sont capables de s’associer à leurs homologues sauvages, engendrant ainsi un DIN même chez les patients hétérozygotes. Ce mémoire présente l’analyse biochimique et fonctionnelle d’une nouvelle mutation naturelle de l’AQP2, la mutation T179N, aussi responsable du DIN. Cette dernière est particulièrement intéressante de par son génotype qui implique un caractère dominant, et sa position extracellulaire habituellement réservée aux mutations récessives. Les études comparatives de T179N à deux modèles de mutation récessive et dominante démontrent, tant en ovocytes de Xenopus laevis qu’en lignée cellulaire mpkCCDc14, le caractère récessif de cette nouvelle mutation. Les tests d’immunobuvardage de lysats d’ovocytes en membranes totales et membranes plasmiques purifiées ont révélé que seule la forme sauvage atteint la membrane plasmique alors que le mutant T179N est séquestré dans la cellule. En accord avec ce résultat, les analyses de perméabilité fonctionnelle démontrent aussi une absence d’activité pour T179N. En cellule mpkCCDc14, le mutant T179N exprimé seul n’atteint pas la membrane plasmique suite à l’action de la forskoline, contrairement à la forme sauvage. Cependant, ce mutant peut s’associer à son homologue sauvage en coexpression tant dans les ovocytes qu’en lignée mpkCCDc14 sans toutefois engendrer l’effet typique de dominance négative. En fait, dans ce contexte de coexpression, on remarque une augmentation de la Pf de 83±7 % et une récupération d’adressage à la membrane plasmique en cellule (immunofluorescence). En conclusion, T179N serait un mutant récessif fonctionnellement récupérable lorsqu’en présence de l’AQP2 sauvage. / Aquaporin-2 (AQP2) is the channel responsible for the final reabsorption of water in the collecting duct of the kidney. Basically, contained in internal vesicles, the AQP2 is delivered to the apical membrane of the principal cells of the collecting tubule after stimulation by the antidiuretic hormone (ADH). The failure to perform this function causes nephrogenic diabetes insipidus (NDI); a disease characterized by the inability of the kidney to concentrate urine and induces the production of high urinary volumes. While recessive mutations generate poorly structured proteins unable to form tetramers, dominant mutations are capable of associating with their wild counterparts, thus generating a NDI even in heterozygous patients. This paper presents the biochemical and functional analysis of T179N, a new NDI-causing mutation of the human AQP2. The mutant is particularly interesting because of its dominant genotype, despite its extracellular position usually restricted to recessive mutations. Here, we compare T179N against archetypal recessive and dominant mutations using both Xenopus laevis oocytes and in mpkCCDc14 cell model, and show the recessive nature of the mutation. The immunoblot tests on oocytes lysates in purified total and plasma membranes revealed that only the wild type protein reaches the plasma membrane while the T179N mutant is sequestered within cellular stores. Accordingly, functional analyzes indicate that T179N is inactive. In mpkCCDc14 cells, T179N expressed alone does not reach the plasma membrane in response to forskolin stimulation, unlike the wild-type. However, T179N does show the capacity to associate with its wild-type counterpart in both oocytes and in mpkCCDc14 cells, although without displaying the typical dominant negative effect. In fact, when coexpressed along wild-type, T179N gains back the functionality, with a Pf increase of 83±7 % and adequate plasma membrane targeting in cells (immunofluorescence). In conclusion, the mutant T179N is a mild recessive mutation that is susceptible to functional recovery when in presence of wild type AQP2.

Os pacientes que usam lítio (Li) para tratamento do transtorno bipolar freqüentemente apresentam poliúria e deficiência de concentração urinária, sintomas do Diabetes Insipidus nefrogênico (DIN). Animais tratados com Li apresentam baixos níveis de produção de adenosina monofosfato cíclico (AMPc) em resposta ao hormônio antidiurético (HAD). O Sildenafil (Sil), um inibidor da fosfodiesterase 5 (PDE5), eleva os níveis intracelulares de guanosina monofosfato cíclico (GMPc), levando a inserção de aquaporina 2 (AQP2) na membrana plasmática das células do ducto coletor. Portanto, inibidores de PDE podem promover a inserção de AQP2 na membrana plasmática mesmo sem a ativação do receptor de HAD, indicando a participação de uma via alternativa mediada pelo GMPc. Nós investigamos o efeito do Sil na expressão renal das proteínas de membrana AQP2, UT-A1, NKCC2, NHE3, P-ENaC em ratos com DIN induzido pelo Li. Ratos Wistar foram divididos nos seguintes grupos: grupo controle, recebendo dieta alimentar normal durante quatro semanas; grupo Li, recebendo dieta alimentar normal com 40 mmol Li por quilo de dieta durante quatro semanas; grupo Li + Sil, recebendo dieta alimentar normal com 40 mmol Li por quilo de dieta durante quatro semanas e 200 mg por quilo de dieta de Sil a partir da segunda semana; grupo Sil, recebendo dieta alimentar normal durante a primeira semana e a partir da segunda semana recebendo dieta normal com 200 mg de Sil por quilo de dieta. Os animais do grupo Li desenvolveram poliúria, diminuição da osmolalidade urinária e diminuição da expressão da AQP2. No grupo Li+Sil, o Sil foi capaz de reverter parcialmente a poliúria, diminuir o clearance de água livre, aumentar a osmolalidade urinária e aumentar a expressão da AQP2. A expressão de UTA1 foi completamente normalizada com o tratamento com Sil. A expressão das proteínas NKCC2 e NHE3 apresentaram-se aumentadas no grupo tratado com Li, e o Sil não foi capaz de reverter tal alteração. Além disso, o tratamento com Sil reverteu completamente o aumento da resistência vascular renal. Assim, concluímos que o tratamento com Sil em ratos com DIN melhora a poliúria, aumenta a smolalidade urinária e diminui o clearance de água livre pelo aumento da expressão de AQP2 e UT-A1. O tratamento com Sil pode ser benéfico para pacientes que sofrem com DIN induzida pelo Li. / Patients taking lithium to treat bipolar disorder often present polyuria and urinary concentrating defect. In addition, lithium-treated animals present lower cyclic adenosine monophosphate production in response to vasopressin. Sildenafil (Sil), a phosphodiesterase 5 (PDE5) inhibitor, elevates intracellular cyclic guanosine monophosphate (cGMP) levels, leading to plasma membrane accumulation of aquaporin 2 (AQP2). Therefore, PDE inhibitors might induce AQP2 membrane insertion even without vasopressin receptor activation by activating a parallel cGMP-mediated signal transduction pathway. We investigated the effect of sildenafil on renal expression of AQP2, UT-A1, sodium/hydrogen exchanger (NHE3), type 1 bumetanide-sensitive Na-K-2Cl cotransporter (NKCC2), and the epithelial sodium channel alpha subunit (P-ENaC). Wistar rats received lithium (40 mmol/kg food) or not for 4 weeks (Li or control), some rats also receiving sildenafil (200 mg/kg food) in weeks 2-4, with or without lithium (Li+Sil or Sil). In Li+Sil rats, urine output was markedly lower, as was water free clearance, whereas urine osmolality was higher. Semiquantitative immunoblotting revealed the following: AQP2 expression was partially normalized; UT-A1 expression was completely normalized; expression of NKCC2 and NHE3 was significantly higher in Li rats (although not significantly different between Li+Sil rats and Li rats); and P-ENaC protein expression was unaltered in all groups. Sildenafil treatment completely reversed the lithium-induced increase in renal vascular resistance. In conclusion, sildenafil treatment of lithium-induced nephrogenic diabetes insipidus (NDI) improves polyuria, increases urinary osmolality, and decreases free water clearance via upregulation of renal AQP2 and UT-A1. Sildenafil treatment could be beneficial in patients with lithium-induced NDI.

Carbamazepina (Carba) é um anticonvulsivante, uma droga psicotrópica muito utilizada no tratamento de pacientes com distúrbios intelectuais. Esta droga foi utilizada para diminuir o volume urinário no Diabetes Insípido (DI), pois possui um efeito antidiurético, mas a incidência de hiponatremia é uma ocorrência comum. O lítio é uma das drogas mais importantes para o tratamento do distúrbio bipolar. No entanto, ele tem uma grande capacidade de induzir DI dificultando o seu uso em pacientes debilitados psicologicamente. Atualmente, a associação destas drogas é frequentemente utilizada para o tratamento de pacientes com distúrbios psiquiátricos e neurológicos. O objetivo deste trabalho foi investigar o efeito da Carba no ducto coletor medular interno (DCMI) de ratos normais e elucidar a sua ação no DI induzido pelo lítio: 1) Estudos in vitro- A) Estudos com microperfusão de segmentos isolados do néfron onde a permeabilidade à água (Pf, m/sec) foi determinada em DCMI perfundidos de ratos normais (n=20) na presença de Carba à 10-5 M, e na ausência de HAD. B) estudos com a técnica de Imunoblotting para avaliar a expressão da proteína Aquaporina 2 (AQP2) em suspensão de túbulos de DCMI de ratos normais incubados com 10-5 M de Carba por 30 minutos. 2) Estudos in vivo A) quatro grupos foram formados: a) Controle (n=5); b) Li (40 mmol/Kg/dieta por 3 semanas; n=4); c) Li+Carba (40 mmol Li/Kg/dieta + 400 mg carba/Kg/dia por 3 semanas; n=5); d) Carba (400 mg /Kg/dia por 3 semanas; n=5); - B) estudo da expressão da AQP2 no DCMI destes quatro grupos pela técnica de Western Blot. Resultados: 1) Estudos in vitro A) nos estudos de microperfusão a carba adicionada ao banho aumentou a Pf dos DCMI, na ausência de HAD (n=6) Controle12,3+ 3,6, Carba-62,6+14,8 (p<0,01), Recuperação (Rec)-17,4+5,5 (p<0,01). Com o intuito de estudar o mecanismo pelo qual a Carba ativa a cascata do HAD, foi utilizado o inibidor do receptor V2 do HAD (AV2; n=10): Controle-23,5+5,2, Carba-37,4±4,4 (p<0,01), Carba+AV2-19,6±5,0 (p<0,05), Rec-21,4+5,5; e Controle-18,6+7,0, AV2-27,3+7,2, AV2+Carba-25,3+5,7, Rec-32,6+6,4. O inibidor da PKA (H8; n=4) também foi utilizado: Controle-15,0+9,0, Carba-106,1+12,3 (p<0,01), Carba+H8-60,3+16,4 (p<0,01), Rec- 44,5+13,2. B) a análise densitométrica mostrou um aumento de 38,8% na expressão da AQP2 (Controle-100,0+8,3 vs. Carba-138,8+12,12, p<0,05); 1) Estudos in vivo Volume urinário (UV, mL/24h) Controle-10,7+3,0, Li-62,6+6,0 (p<0,001), Li+Carba-28,5+4,9 (p<0,001), Carba-23,3+3,0 (<0,001). Osmolalidade urinária (mOsm/Kg/H2O) Controle-819,6+175,7, Li-149,4+18,0 (p<0,01), Li+Carba-251,5+39,7 (p<0,05), Carba-396,2+75,5 (p<0,01). FENa+ (%) - Controle-0,15+0,01, Li-0,10+0,02, Li+Carba-0,12+0,02, Carba-0,11+0,02. Expressão da AQP2 (%) Controle-100,0+6,7, Li-55,8+5,4 (p<0,01), Li+Carba-75,8+9,6 (p<0,01), Carba- 99,7+4,7 (p<0,05). Não houve diferenças significantes no Na+, K+ e Osmolalidade plasmáticas. Em resumo, nossos dados revelaram que a Carba diminui o UV, aumenta a osmolalidade urinária e a expressão da AQP2 no DI induzido pelo lítio, e aumenta a permeabilidade à água, provavelmente agindo diretamente no receptor da vasopressina (V2). Estes resultados enfatizam que a hiponatremia encontrada nos pacientes que fazem uso da Carba pode ser explicada, pelo menos em parte, pelo aumento da permeabilidade osmótica no DCMI e que a poliúria do DI ocasionado pelo uso do lítio pode ser diminuída com a associação da Carba. / Carbamazepine (Carba) is an anticonvulsant and a psychotropic medication commonly used in the treatment of patients with intellectual disability (ID). This drug has been used to try to decrease the urinary volume in Diabetes Insipidus (DI) because Carba presents an antidiuretic effect, but the incidence of the hyponatremia in neurological patients is a common ocurrence. Lithium (Li) is one of the most important drugs used to treat bipolar mood disorders. However, Li has the undesirable capacity to induce DI complicating its usage in patients psychologically weakened. Nowadays, the association of these drugs is used in the treatment of patients with psychiatric and neurological problems. Our objective was to investigate the effect of Carba in the Inner Medullary Collecting Duct (IMCD) and elucidate its effect in the lithium-induced DI: 1) In vitro study: A) Microperfusion studies the water permeability (Pf, m/sec) was determined in normal rats IMCD isolated and perfused by the standard methods. Carba 10-5M was added to the bath fluid. B) Immunoblotting studies for AQP2 protein expression in IMCD tubule suspension from normal rats incubated with Carba 10-5M for 30 minutes. 2) In vivo study A) four groups of normal rats were done - a) Control (C, n=5); b) Li (40 mmol/kg/food/3 weeks n=4) c) Li+Carba (40 mmol Li/kg/food/3 weeks and 400 mg Carba/kg/bw/2 last weeks, n=5); and Carba (400 mg Carba/kg/bw/3weeks, n=5); - B) AQP2 expression in IMCD from the four groups, by Western Blot. Results: 1) In vitro study A) in microperfusion, Carba added to the bath in Vasopressin (Vp) absence (n=6) increased Pf Control-12.3+3.6, Carba-62.6+14.8 (p<0.01), Recuperation (Rec)-17.4+5.5 (p<0.01). In order to study the mechanism by which Carba activates the Vp cascade, the antagonist of the Vp receptor 2 (AV2; n=10) was used: Control-23.5+5.2, Carba-37.4±4.4 (p<0.01), Carba+AV2-19.6±5.0 (p<0.05), Rec-21.4+5.5; and Control-18.6+7.0, AV2- 27.3+7.2, AV2+Carba-25.3+5.7, Rec-32.6+6.4. The PKA inhibitor (H8; n=4) was also used: Control-15.0+9.0, Carba-106.1+12.3 (p<0,01), Carba+H8-60.3+16.4 (p<0.01), Rec-44.5+13.2. B) the densitometric analysis showed an increased of 38.8% in AQP2 expression (Control- 100.0+8.3 vs. Carba-138.8+12.12, p<0.05); B) In vivo study Urinary volume (UV, mL/24h) Control-10.7+3.0, Li-62.6+6.0 (p<0.001), Li+Carba-28.5+4.9 (p<0.001), Carba-23.3+3.0 (p<0.001). Urinary Osmolality (mOsm/Kg/H2O) Control-819.6+175.7, Li-149.4+18.0 (p<0.01), Li+Carba-251.5+39.7 (p<0.05), Carba-396.2+75.5 (p<0.01). FENa+ (%) - Control- 0.15+0.01, Li-0.10+0.03, Li+Carba-0.12+0.02, Carba-0.11+0.02. AQP2 expression (%) Control-100.0+6.7, Li-55.8+5,4 (p<0.01), Li+Carba-75.8+9.6 (p<0.01), Carba-99.7+4.7 (p<0.05). There were no significant differences in Na+, K+ and plasma osmolality. In summary, our data showed that Carba decreased the UV, increased the UOsm and the AQP2 expression in Li-induced DI, increased the water permeability, probably acting directly in the Vp V2 receptor-Protein G complex, since its action was blocked by the specific Vp V2 receptor antagonist. These results emphazise that the hyponatremia found in patients using Carba could be explained, at least in part, by increased osmotic permeability of IMCD. In addition, poliuria observed in lithium-induced DI can be decreased with Carba-treatment.

Bakgrund: Kontrastmedel används inom medicinsk avbildning för att tolka anatomi och patologi. Gadolinium är den vanligaste typen av kontrastmedel som används inom magnetresonanstomografi (MRT). Eftersom gadolinium är ett läkemedel kan det orsaka biverkningar. Studier har visat att det finns ett samband mellan insjuknandet av nefrogen systemisk fibros (NSF) och gadoliniumkontrastmedel hos njursjuka patienter. Syfte: Att ta reda på vilka biverkningar som kan uppstå efter en gadoliniumkontrastmedelsinjektion och redogöra för hur vanligt förekommande de är. Utöver detta undersöka om patienter med nedsatt njurfunktion insjuknar i NSF av gadoliniumkontrastmedel. Metod: Studien genomfördes som en systematisk litteraturstudie. Resultat: Omtalade biverkningar är skelettsmärta, huvudvärk, illamående, kräkningar och hudförändringar. Ångest, oro, influensaliknande symptom, klåda, osammanhängande tankegång, metallsmak i munnen, ledstelhet och muskelspasm är mindre omtalade biverkningar. Svåra biverkningar förekommer såsom struphuvudsödem, anafylaktisk chock, andningssvårigheter, dyspné och medvetslöshet. Milda biverkningar är mest förekommande. Fyra fall av NSF konstateras i en studie med 261 njursjuka deltagare. I en annan studie med 571 dialyspatienter bekräftades inga fall av NSF. Slutsats: Förekomsten för en biverkning är sällsynt men både omtalade och mindre omtalade biverkningar kan inträffa. Det finns studier som visar ett tydligt samband mellan NSF och gadolinium hos patienter med nedsatt njurfunktion medan andra studier inte kan bekräfta det. Gadoliniumkontrastmedel är relativt riskfritt men observation av patienten bör alltid förekomma. / Background: Contrast media are used in medical imaging to picture anatomy and pathology. Gadolinium is the most common type of contrast media used in magnetic resonance imaging (MRI). The use of gadolinium may cause adverse effects. The association between gadolinium-based contrast media and nephrogenic systemic fibrosis (NSF) in patients with renal insufficiency has been described in earlier studies. Purpose: To describe the most frequent adverse effects caused by gadolinium-based contrast media and their incidence. The study also aims to explain the association between NSF and gadolinium in patients with renal insufficiency. Method: The study has been conducted as a systematic literature review. Results: The well-known adverse effects are bone pain, headache, nausea, vomiting, and skin lesions. Anxiety, flu-like symptoms, pruritus, clouded mentation, metallic taste in the mouth, joint stiffness and muscle spasm are less mentioned. Severe adverse effects also exist such as laryngeal-edema, anaphylactic shock, breathing difficulty, dyspnea and unconsciousness. Mild adverse effects are most common. Four cases of NSF were found in a study with 261 participants with renal disease. In another study 571 patients with dialysis treatment were included, no cases of NSF were confirmed. Conclusion: Both well-known adverse effects and less mentioned adverse effects exist but the occurrence of an adverse effect is rare. There are studies showing a clear association between NSF and gadolinium in patients with renal insufficiency, whilst others can´t confirm it. Gadolinium-based contrast media is relatively risk-free but observation of the patient should always occur.

Carbamazepina (Carba) é um anticonvulsivante, uma droga psicotrópica muito utilizada no tratamento de pacientes com distúrbios intelectuais. Esta droga foi utilizada para diminuir o volume urinário no Diabetes Insípido (DI), pois possui um efeito antidiurético, mas a incidência de hiponatremia é uma ocorrência comum. O lítio é uma das drogas mais importantes para o tratamento do distúrbio bipolar. No entanto, ele tem uma grande capacidade de induzir DI dificultando o seu uso em pacientes debilitados psicologicamente. Atualmente, a associação destas drogas é frequentemente utilizada para o tratamento de pacientes com distúrbios psiquiátricos e neurológicos. O objetivo deste trabalho foi investigar o efeito da Carba no ducto coletor medular interno (DCMI) de ratos normais e elucidar a sua ação no DI induzido pelo lítio: 1) Estudos in vitro- A) Estudos com microperfusão de segmentos isolados do néfron onde a permeabilidade à água (Pf, m/sec) foi determinada em DCMI perfundidos de ratos normais (n=20) na presença de Carba à 10-5 M, e na ausência de HAD. B) estudos com a técnica de Imunoblotting para avaliar a expressão da proteína Aquaporina 2 (AQP2) em suspensão de túbulos de DCMI de ratos normais incubados com 10-5 M de Carba por 30 minutos. 2) Estudos in vivo A) quatro grupos foram formados: a) Controle (n=5); b) Li (40 mmol/Kg/dieta por 3 semanas; n=4); c) Li+Carba (40 mmol Li/Kg/dieta + 400 mg carba/Kg/dia por 3 semanas; n=5); d) Carba (400 mg /Kg/dia por 3 semanas; n=5); - B) estudo da expressão da AQP2 no DCMI destes quatro grupos pela técnica de Western Blot. Resultados: 1) Estudos in vitro A) nos estudos de microperfusão a carba adicionada ao banho aumentou a Pf dos DCMI, na ausência de HAD (n=6) Controle12,3+ 3,6, Carba-62,6+14,8 (p<0,01), Recuperação (Rec)-17,4+5,5 (p<0,01). Com o intuito de estudar o mecanismo pelo qual a Carba ativa a cascata do HAD, foi utilizado o inibidor do receptor V2 do HAD (AV2; n=10): Controle-23,5+5,2, Carba-37,4±4,4 (p<0,01), Carba+AV2-19,6±5,0 (p<0,05), Rec-21,4+5,5; e Controle-18,6+7,0, AV2-27,3+7,2, AV2+Carba-25,3+5,7, Rec-32,6+6,4. O inibidor da PKA (H8; n=4) também foi utilizado: Controle-15,0+9,0, Carba-106,1+12,3 (p<0,01), Carba+H8-60,3+16,4 (p<0,01), Rec- 44,5+13,2. B) a análise densitométrica mostrou um aumento de 38,8% na expressão da AQP2 (Controle-100,0+8,3 vs. Carba-138,8+12,12, p<0,05); 1) Estudos in vivo Volume urinário (UV, mL/24h) Controle-10,7+3,0, Li-62,6+6,0 (p<0,001), Li+Carba-28,5+4,9 (p<0,001), Carba-23,3+3,0 (<0,001). Osmolalidade urinária (mOsm/Kg/H2O) Controle-819,6+175,7, Li-149,4+18,0 (p<0,01), Li+Carba-251,5+39,7 (p<0,05), Carba-396,2+75,5 (p<0,01). FENa+ (%) - Controle-0,15+0,01, Li-0,10+0,02, Li+Carba-0,12+0,02, Carba-0,11+0,02. Expressão da AQP2 (%) Controle-100,0+6,7, Li-55,8+5,4 (p<0,01), Li+Carba-75,8+9,6 (p<0,01), Carba- 99,7+4,7 (p<0,05). Não houve diferenças significantes no Na+, K+ e Osmolalidade plasmáticas. Em resumo, nossos dados revelaram que a Carba diminui o UV, aumenta a osmolalidade urinária e a expressão da AQP2 no DI induzido pelo lítio, e aumenta a permeabilidade à água, provavelmente agindo diretamente no receptor da vasopressina (V2). Estes resultados enfatizam que a hiponatremia encontrada nos pacientes que fazem uso da Carba pode ser explicada, pelo menos em parte, pelo aumento da permeabilidade osmótica no DCMI e que a poliúria do DI ocasionado pelo uso do lítio pode ser diminuída com a associação da Carba. / Carbamazepine (Carba) is an anticonvulsant and a psychotropic medication commonly used in the treatment of patients with intellectual disability (ID). This drug has been used to try to decrease the urinary volume in Diabetes Insipidus (DI) because Carba presents an antidiuretic effect, but the incidence of the hyponatremia in neurological patients is a common ocurrence. Lithium (Li) is one of the most important drugs used to treat bipolar mood disorders. However, Li has the undesirable capacity to induce DI complicating its usage in patients psychologically weakened. Nowadays, the association of these drugs is used in the treatment of patients with psychiatric and neurological problems. Our objective was to investigate the effect of Carba in the Inner Medullary Collecting Duct (IMCD) and elucidate its effect in the lithium-induced DI: 1) In vitro study: A) Microperfusion studies the water permeability (Pf, m/sec) was determined in normal rats IMCD isolated and perfused by the standard methods. Carba 10-5M was added to the bath fluid. B) Immunoblotting studies for AQP2 protein expression in IMCD tubule suspension from normal rats incubated with Carba 10-5M for 30 minutes. 2) In vivo study A) four groups of normal rats were done - a) Control (C, n=5); b) Li (40 mmol/kg/food/3 weeks n=4) c) Li+Carba (40 mmol Li/kg/food/3 weeks and 400 mg Carba/kg/bw/2 last weeks, n=5); and Carba (400 mg Carba/kg/bw/3weeks, n=5); - B) AQP2 expression in IMCD from the four groups, by Western Blot. Results: 1) In vitro study A) in microperfusion, Carba added to the bath in Vasopressin (Vp) absence (n=6) increased Pf Control-12.3+3.6, Carba-62.6+14.8 (p<0.01), Recuperation (Rec)-17.4+5.5 (p<0.01). In order to study the mechanism by which Carba activates the Vp cascade, the antagonist of the Vp receptor 2 (AV2; n=10) was used: Control-23.5+5.2, Carba-37.4±4.4 (p<0.01), Carba+AV2-19.6±5.0 (p<0.05), Rec-21.4+5.5; and Control-18.6+7.0, AV2- 27.3+7.2, AV2+Carba-25.3+5.7, Rec-32.6+6.4. The PKA inhibitor (H8; n=4) was also used: Control-15.0+9.0, Carba-106.1+12.3 (p<0,01), Carba+H8-60.3+16.4 (p<0.01), Rec-44.5+13.2. B) the densitometric analysis showed an increased of 38.8% in AQP2 expression (Control- 100.0+8.3 vs. Carba-138.8+12.12, p<0.05); B) In vivo study Urinary volume (UV, mL/24h) Control-10.7+3.0, Li-62.6+6.0 (p<0.001), Li+Carba-28.5+4.9 (p<0.001), Carba-23.3+3.0 (p<0.001). Urinary Osmolality (mOsm/Kg/H2O) Control-819.6+175.7, Li-149.4+18.0 (p<0.01), Li+Carba-251.5+39.7 (p<0.05), Carba-396.2+75.5 (p<0.01). FENa+ (%) - Control- 0.15+0.01, Li-0.10+0.03, Li+Carba-0.12+0.02, Carba-0.11+0.02. AQP2 expression (%) Control-100.0+6.7, Li-55.8+5,4 (p<0.01), Li+Carba-75.8+9.6 (p<0.01), Carba-99.7+4.7 (p<0.05). There were no significant differences in Na+, K+ and plasma osmolality. In summary, our data showed that Carba decreased the UV, increased the UOsm and the AQP2 expression in Li-induced DI, increased the water permeability, probably acting directly in the Vp V2 receptor-Protein G complex, since its action was blocked by the specific Vp V2 receptor antagonist. These results emphazise that the hyponatremia found in patients using Carba could be explained, at least in part, by increased osmotic permeability of IMCD. In addition, poliuria observed in lithium-induced DI can be decreased with Carba-treatment.

Os pacientes que usam lítio (Li) para tratamento do transtorno bipolar freqüentemente apresentam poliúria e deficiência de concentração urinária, sintomas do Diabetes Insipidus nefrogênico (DIN). Animais tratados com Li apresentam baixos níveis de produção de adenosina monofosfato cíclico (AMPc) em resposta ao hormônio antidiurético (HAD). O Sildenafil (Sil), um inibidor da fosfodiesterase 5 (PDE5), eleva os níveis intracelulares de guanosina monofosfato cíclico (GMPc), levando a inserção de aquaporina 2 (AQP2) na membrana plasmática das células do ducto coletor. Portanto, inibidores de PDE podem promover a inserção de AQP2 na membrana plasmática mesmo sem a ativação do receptor de HAD, indicando a participação de uma via alternativa mediada pelo GMPc. Nós investigamos o efeito do Sil na expressão renal das proteínas de membrana AQP2, UT-A1, NKCC2, NHE3, P-ENaC em ratos com DIN induzido pelo Li. Ratos Wistar foram divididos nos seguintes grupos: grupo controle, recebendo dieta alimentar normal durante quatro semanas; grupo Li, recebendo dieta alimentar normal com 40 mmol Li por quilo de dieta durante quatro semanas; grupo Li + Sil, recebendo dieta alimentar normal com 40 mmol Li por quilo de dieta durante quatro semanas e 200 mg por quilo de dieta de Sil a partir da segunda semana; grupo Sil, recebendo dieta alimentar normal durante a primeira semana e a partir da segunda semana recebendo dieta normal com 200 mg de Sil por quilo de dieta. Os animais do grupo Li desenvolveram poliúria, diminuição da osmolalidade urinária e diminuição da expressão da AQP2. No grupo Li+Sil, o Sil foi capaz de reverter parcialmente a poliúria, diminuir o clearance de água livre, aumentar a osmolalidade urinária e aumentar a expressão da AQP2. A expressão de UTA1 foi completamente normalizada com o tratamento com Sil. A expressão das proteínas NKCC2 e NHE3 apresentaram-se aumentadas no grupo tratado com Li, e o Sil não foi capaz de reverter tal alteração. Além disso, o tratamento com Sil reverteu completamente o aumento da resistência vascular renal. Assim, concluímos que o tratamento com Sil em ratos com DIN melhora a poliúria, aumenta a smolalidade urinária e diminui o clearance de água livre pelo aumento da expressão de AQP2 e UT-A1. O tratamento com Sil pode ser benéfico para pacientes que sofrem com DIN induzida pelo Li. / Patients taking lithium to treat bipolar disorder often present polyuria and urinary concentrating defect. In addition, lithium-treated animals present lower cyclic adenosine monophosphate production in response to vasopressin. Sildenafil (Sil), a phosphodiesterase 5 (PDE5) inhibitor, elevates intracellular cyclic guanosine monophosphate (cGMP) levels, leading to plasma membrane accumulation of aquaporin 2 (AQP2). Therefore, PDE inhibitors might induce AQP2 membrane insertion even without vasopressin receptor activation by activating a parallel cGMP-mediated signal transduction pathway. We investigated the effect of sildenafil on renal expression of AQP2, UT-A1, sodium/hydrogen exchanger (NHE3), type 1 bumetanide-sensitive Na-K-2Cl cotransporter (NKCC2), and the epithelial sodium channel alpha subunit (P-ENaC). Wistar rats received lithium (40 mmol/kg food) or not for 4 weeks (Li or control), some rats also receiving sildenafil (200 mg/kg food) in weeks 2-4, with or without lithium (Li+Sil or Sil). In Li+Sil rats, urine output was markedly lower, as was water free clearance, whereas urine osmolality was higher. Semiquantitative immunoblotting revealed the following: AQP2 expression was partially normalized; UT-A1 expression was completely normalized; expression of NKCC2 and NHE3 was significantly higher in Li rats (although not significantly different between Li+Sil rats and Li rats); and P-ENaC protein expression was unaltered in all groups. Sildenafil treatment completely reversed the lithium-induced increase in renal vascular resistance. In conclusion, sildenafil treatment of lithium-induced nephrogenic diabetes insipidus (NDI) improves polyuria, increases urinary osmolality, and decreases free water clearance via upregulation of renal AQP2 and UT-A1. Sildenafil treatment could be beneficial in patients with lithium-induced NDI.

La fibrose systémique néphrogénique (FSN) est une maladie rare et relativement récente, observée uniquement chez des patients souffrant d’insuffisance rénale sévère ou terminale. Elle est liée à l’administration d’une certaine catégorie de complexes de gadolinium (CG), les CGs thermodynamiquement moins stables, utilisés comme produits de contraste pour l’imagerie par résonance magnétique. L’hypothèse mécanistique la plus couramment citée concerne les effets profibrosants du Gd3+ « libre » après dissociation in vivo des CGs les moins stables mais il n’en existe pas de démonstration formelle. La physiopathologie de cette maladie reste mal connue, notamment par manque de modèles précliniques pertinents. Les travaux de cette thèse répondent donc à la nécessité d’approfondir nos connaissances concernant les relations entre les propriétés physicochimiques des CGs (structure, stabilité) et le risque de toxicité chronique, afin de mieux comprendre leur rôle dans le mécanisme de la FSN. Nous avons mis aux points plusieurs modèles de FSN chez le Rat. Nous avons aussi comparé les effets de toutes les catégories structurales des CGs sur ces modèles. Une toxicité systémique importante et la survenue de lésions cutanées macroscopiques et d’une fibrose du derme sont notées après administration de gadodiamide (un CG linéaire et ionique de faible stabilité), ce qui est cohérent avec le fait que la grande majorité des cas de FSN sont associés à cet agent. Nous avons aussi montré que cette toxicité dépend du degré d’insuffisance rénale et que l’hyperphosphatémie sensibilise les animaux aux effets profibrosants du gadodiamide. Nos données suggèrent donc que ces facteurs associés sont des facteurs de risque de la FSN. Nous avons observé la dissociation progressive in vivo de deux CGs linéaires présentant une faible stabilité, le gadodiamide et l’acide gadopentétique, après administration chez le Rat insuffisant rénal, avec libération de Gd3+ sous forme libre et soluble. Les CGs macrocycliques sont restés stables. Nous avons confirmé cette stabilité sur du sérum de Rat et du sérum humain alors que le gadodiamide se dissocie in vitro. Nos données suggèrent aussi une interaction entre l’ion Gd3+ dissocié à partir du gadodiamide et les protéines sériques. Cette libération de Gd3+ est accélérée en présence d’une forte concentration de phosphate. Globalement, nos résultats suggèrent ainsi un rôle causal du Gd3+ libre dans les lésions cutanées observées chez les animaux insuffisants rénaux. Enfin, nous avons observé l’implication de la voie de signalisation canonique de TGFβ, le marqueur clé de la fibrose, uniquement chez des rats ayant reçu le gadodiamide et dont l’insuffisance rénale est modérée. Nos travaux sont donc en faveur de l’hypothèse mécanistique d’une dissociation des CGs peu stables. / Nephrogenic systemic fibrosis (NSF) is a rare systemic fibrosing disorder which has been described in patients with severe or end stage renal failure. NSF is associated with prior administration of certain gadolinium complexes (GCs), used as magnetic resonance imaging contrast agents, particularly those which have the lowest thermodynamic stability. The most widely accepted hypothesis regarding the mechanism is based on profibrotic effects of free Gd3+ following in vivo dissociation of the less stable GCs. Nevertheless, there is no conclusive evidence so far. The pathophysiology is not completely understood, especially due to the lack of relevant non-clinical models. The purpose of our thesis was to investigate the relationship between physicochemical properties of GCs (molecular structure, thermodynamic stability) and the risk of chronic toxicity (especially fibrosis), in order to enhance our understanding of their role in the mechanism of NSF. We have set-up various non-clinical models of NSF in renally-impaired rats. We also compared the effects of all categories of GCs on these models. A high systemic toxicity, associated with macroscopic skin lesions and dermal fibrosis, was observed after the administration of gadodiamide (a linear and nonionic GC with a low thermodynamic stability). Whereas more stable, macrocyclic GCs were well tolerated. These findings seem clinically-relevant because the vast majority of NSF cases are associated with gadodiamide. We also showed that systemic and skin toxicities depend on the baseline renal function, and that hyperphosphataemia sensitizes renally-impaired rats to the fibrotic effects of gadodiamide. Our data suggest that these factors are, actually, risk factors for NSF. We observed in vivo dissociation of two linear GCs, gadodiamide and gadopentetic acid, with gradual release of soluble Gd3+, in renally-impaired rats. Macrocyclic agents remained stable. This observation was also confirmed both in rat and human serum by the relaxometry technique. Our results are also consistent with an interaction between dissociated Gd3+ and serum proteins. We also demonstrated that elevated serum phosphate levels accelerates the release of Gd3+. Taken all together, our results suggest a causal role of dissociated Gd3+ in gadodiamide-induced skin lesions in renally-impaired rats. Finally, we identified the involvement of the canonical signaling pathway of TGFβ, the central mediator of the fibrotic response, in gadodiamide-treated rats with a moderate renal failure. Our work is consistent with a causal role of dissociated Gd in the mechanism of NSF.