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Clinical Studies |
Division of Endocrinology and Metabolism (Ta.S., S.I., T.N., K.R., A.K. K.H., To.S.), Department of Medicine, Jichi Medical School, Tochigi 32904; and Second Department of Internal Medicine (S.S., F.M.), Tokyo Medical and Dental University, Tokyo 113, Japan
Address all correspondence and requests for reprints to: San-e Ishikawa, M.D., Division of Endocrinology and Metabolism, Department of Medicine, Jichi Medical School, 33111 Yakushiji Minamikawachi-machi, Tochigi, 32904, Japan. E-mail: saneiskw{at}jichi.ac.jp
| Abstract |
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| Introduction |
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Impaired secretion of AVP from posterior pituitary occurs in patients with CDI (16). The patients suffer from polyuria and polydipsia because of the disturbance of renal water reabsorption in collecting duct cells. The disease has been diagnosed by the diminished secretion of AVP in response to hypertonic saline infusion or water deprivation testing (17). However, we have sometimes experienced unreliable diagnosis of CDI, because current diagnostic approach is limited.
The present study therefore was undertaken to determine whether urinary excretion of AQP-2 is of value in diagnosing CDI. We measured urinary excretion of AQP-2 by RIA in the normal subjects and the patients with CDI.
| Subjects and Methods |
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Sixteen normal subjects, 2128 yr old, were divided into two groups. They were 11 males and 5 females. A group of 6 normal subjects drank water ad libitum; 30-min urine samples were taken and blood drawn at 0900 h. The other group of 10 normal subjects was prohibited water drinking from 2100 h a day before, and blood and 30-min urine samples were taken at 0900 h. Urine samples were subjected to measurement of urinary osmolality (Uosm) and urinary excretion of creatinine and AQP-2. Blood samples were used to measure plasma osmolality (Posm) and plasma AVP levels.
Hypertonic saline test
Hypertonic saline testing was carried out in 2 groups of subjects. The present protocol was approved by the ethical committee of Jichi Medical School Hospital for human study. We obtained informed consent from all the subjects to join the present protocol. The 1st group had 5 normal volunteers, with ages ranging from 2125 yr (22.5 ± 0.2, mean± SE). They were 4 males and 1 female. The 2nd group of 10 patients had been diagnosed as idiopathic CDI. They were 7 males and 3 females, whose ages ranged from 2268 yr (44.8 ± 5.6, mean ± SE). They had taken 1-deamino-8-D-AVP intranasally twice a day and discontinued the 1-deamino-8-D-AVP therapy 24 h before the start of the study.
After an overnight fast, the study was started at 0900 h. The subjects were allowed to drink water freely before the start of the present protocol. After urination, water (20 mL/kg) was given orally for 60 min. Thirty minutes later, 5% NaCl was administered iv at a rate of 0.05 mL/kg·min for 120 min. Thirty-minute urine collections were made during the observation period. Blood samples were collected at 15, 120, and 240 min. Thereafter, exogenous AVP at a dose of 0.1U, dissolved in 1 mL distilled water, was given iv. Two 15-min urine collections were made, and a blood sample was collected at 245 min. Urine and blood samples were subjected to measurement of urine volume, Uosm, urinary excretion of creatinine and AQP-2, serum sodium, Posm, and plasma AVP levels.
Uosm and Posm were measured by freezing-point depression (Model 3W2, Advanced Instrument, Needham Height, MA). Urinary creatinine in each urine sample was measured with an automatic clinical analyzer (Model 736, Hitachi Co., Tokyo, Japan), and serum Na was measured by flame photometer (Model 736, Hitachi Co.). Plasma AVP levels were measured by RIA using AVP RIA kits (Mitsubishi Chemistry, Tokyo, Japan), as described previously (18, 19). Urinary AQP-2 was determined as described below.
RIA of urinary AQP-2
The RIA of urinary AQP-2 was performed by the modified method described in our previous report (12). Urinary AQP-2-like immunoreactivity was measured by a specific RIA that used the polyclonal antibody against a synthetic portion of the C-terminal of human AQP-2 raised in rabbits (4, 12). A synthetic peptide (Tyr0.aquaporin-2[V257-A27l]), corresponding to the 15-amino-acid sequence of the C-terminal of AQP-2, was radioiodinated with iodine-125 (New England Nuclear, Boston, MA) by the chloramin T method, as described elsewhere (20). For the assay, 0.1 mL of the urine sample (diluted 1x:8x) or of a standard, 0.1 mL of assay buffer \[0.05 mol/L sodium phosphate (pH 7.4), 0.08 mol/L sodium chloride, 0.0l mol/L ethylenediamine tetra-acetate, 0.5% BSA, 0.5% NP-40, and 0.01% sodium azide\], and 0.1 mL of the antibody (final dilution, 1:12,000) were incubated at 4°C for 48 h, followed by the addition of 0.1 mL of the radiolabeled synthetic peptide (approximately l0,000 cpm) and further incubation at 4°C for 48 h. Bound and free quantities of radiolabeled ligand were separated by the double-antibody method. The serial dilution curve of the urine samples was parallel to that of the standard (data not shown). Each sample was analyzed in duplicate, and the intra- and interassay coefficients of variation were less than 10%. The minimal detectable quantity of AQP-2 was 0.86 pmol/tube, and an amount equivalent to 20.74 pmol/tube caused 50% inhibition of binding of the radiolabeled ligand. When the 8x diluted urine samples (0.1 mL) were used, the range of results were distributed between 0.9 and 24.2 pmol/tube on the standard curve. Most of urinary AQP-2 levels in the patients with CDI were present at and around the minimal detectable levels on the standard curves.
Statistical analysis
The values of urine volume, Uosm, Posm, serum Na, plasma AVP levels, and the excretion of urinary AQP-2 were expressed as means ± SE. All values were compared with two-way ANOVA and Fishers t test. A P-value less than 0.05 was considered significant.
| Results |
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| Discussion |
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The response of urinary excretion of AQP-2 to endogenous and exogenous
AVP seems to be different. An increase in urinary excretion of AQP-2
was slow and its magnitude was 12-fold during the 5%-NaCl infusion
test in the normal subjects. The percent change in urinary AQP-2 was
much greater than that in plasma AVP after the 5%-NaCl administration
in the normal subjects. This finding may depend upon the widely
changeable range in urinary excretion of AQP-2, as compared with plasma
AVP. The administration of exogenous AVP further produced a prompt
increase in urinary excretion of AQP-2. However, as shown in Fig. 3
, urine volume did not further decrease and Uosm did not further increase
after the exogenous AVP in the normal subjects. In the patients with
CDI, urinary excretion of AQP-2 did not respond to the 5%-NaCl
infusion and remained low. Urinary excretion of AQP-2 markedly
exaggerated in response to the administration of exogenous AVP, a value
similar to that in the normal subjects. There may be a marked
difference in the peak levels of plasma AVP between the 5%-NaCl
infusion and the exogenous administration of AVP. The maneuver of
exogenous AVP administration may have to transiently elevate plasma AVP
levels to a large extent, though we did not measure plasma AVP levels
immediately after the iv administration of AVP. Such a change may be
closely related to a prompt increase in urinary excretion of AQP-2. The
present finding suggested that a shuttle trafficking of AQP-2 is
considerably fast in renal collecting duct cells, and AQP-2 is
simultaneously excreted into the urine.
We would evaluate the efficacy of urinary excretion of AQP-2 in
diagnosis of CDI. The basal levels of urinary excretion of AQP-2 in the
patients with CDI was one eighth of that in the normal subjects.
Urinary excretion of AQP-2 was positively correlated with plasma AVP
levels (Fig. 1
). Five percent-NaCl infusion testing showed that urinary
excretion of AQP-2 gradually increased in response to an increase in
Posm, mediated via AVP secretion, in the normal subjects. However, no
alteration in urinary excretion of AQP-2 was observed in the patients
with CDI. We consider that the observation period should be prolonged
after ceasing 5%-NaCl infusion; i.e., two more 30-min urine
collections may have to be made before the administration of exogenous
AVP. The present study strongly indicated that the measurement of
urinary AQP-2 is a useful tool for diagnosing CDI, in addition to other
parameters previously evaluated. We should modify the maneuver of
5%-NaCl testing to further clarify the changes in urinary excretion of
AQP-2.
| Footnotes |
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Received December 24, 1996.
Revised February 19, 1997.
Accepted February 26, 1997.
| References |
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