JOURNAL

OF SURGICAL

RESEARCH

26, 348-354 (1979)

Catecholamine Responses to Orthostatic Stimulation in Anephric Man1 ELLIOTT M. BADDER,

M.D.,*s2 FUAD DAGHER, M.D.,*

JOHN F. SEATON, B.Sc,t

AND TIMOTHY S. HARRISON, M.D.t *Department of Surgery. University of Maryland Hospital, Baltimore, Maryland 21201, and TDepartments of Surgery and Physiology, Hershey Medical Center, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania 17033 Presented at the Annual Meeting of the Association for Academic Cleveland, Ohio, November 12- 15, 1978

Surgery,

Acute experiments on nephrectomized animals suggest inhibition of adrenergic reflexes in the absence of renal humoral factors. That renal failure patients rendered anephric for control of hypertension also have difficulty with blood pressure regulation is confirmed by the blood pressure instability and hemodialysis shock in anephric patients. In the present study, anephric patients were stimulated by passive orthostatic tilting to the 75”, head-up position. Elevated plasma arterial and venous epinephrine and norepinephrine contents were found at rest and after tilting. The relative increase in circulating catecholamines after tilting is consistent with previous studies in normal patients. The resting elevation of catecholamines in these anephric patients suggests either loss of a renal factor restraining adrenergic activity or a chronic stimulus to sympathetic discharge such as hypovolemia.

INTRODUCTION

Important renal humoral influences on adrenergic reflexes are recognized in animal studies [l- 121. Renal release of both prostaglandins and renin with subsequent angiotensin II production may modify such sympathetic functions as blood pressure regulation and organ flow responses to hypovolemia [l-9]. A potentially separate and as yet poorly characterized renal humoral factor is thought to support vascular capacitance by maintaining venous vasomotor tone [ 10, 111. In acutely anephric dogs, reflex adrenal medulhu-y secretion, an important source of plasma catecholamines, is markedly inhibited following hemorrhage and restored by angiotensin II infusion [3]. Adrenal medullary catecholamine release following hemorrhage is completely absent in acutely anephric cats [12]. In man, the role is not established of renal 1Supported in part by HEW Grant HL 18995. 2 Address reprint requests to: Elliott M. Badder, M.D., Mercy Hospital, 301 St. Paul Place, Baltimore, Md. 21202. 0022~4804/79/040348-07$01.00/O Copyright 0 1979 by Academic Press, Inc. AU rights of reproduction in any form reserved.

factors in supporting sympathetic reflex activity. A renal contribution to some forms of hypertension is well known and indicates at least a complementary role for the kidney in support of blood pressure 113,141. Excess renin secretion is thought to cause hypertension in some patients [ 13,141; and recently, depressed renal prostaglandin excretion has been described in patients with essential hypertension [7]. A few end-stage renal failure patients require bilateral nephrectomy for control of severe hypertension [ 151. These patients are unique in that they lack kidney hormones while lost renal excretory function is corrected by chronic hemodialysis. Blood pressure lability in such patients suggests defective control of vasomotor tone [ 161. In the present investigation, a group of patients with end-stage renal failure awaiting complete nephrectomy for control of severe hypertension, a group of similar patients with blood pressure controlled following bilateral nephrectomy, and two kidney transplant recipients previously nephrectomized for hypertension control were selected for 348

BADDER

ET AL.: CATECHOLAMINE

RESPONSES

TO ORTHOSTATIC

STIMULATION

349

study. The changes from resting arterial and 2 hr. After 1.5 hr, a 21-gauge butterfly needle venous content of norepinephrine (NE) and with heparinized saline syringe (3 cc) was epinephrine (E) to concentrations stimulated inserted into an antecubital vein using sterile by passive orthostatic tilting were deter- technique in the arm contralateral to the mined as a measure of sympathetic reflex arterial-venous fistula or shunt. A similar responsiveness in these patients. needle was placed in the arterialized vein of the arterial-venous fistula. After 0.5 hr MATERIALS AND METHODS additional rest in the supine position, simultaneous arterialized and venous bloods were Patients were selected for study among withdrawn (2 ml per sample). Pulse and those patients with end-stage renal failure blood pressure (Tycos sphygmomanometer) and poorly controlled hypertension followed at the University of Maryland Hospital were recorded. Following blood sampling, patients were tilted slowly (30 to 60 set) dialysis unit. Three patients were studied prior to nephrectomy. All required antihy- and passively to the 75”d, head-up position. pertensive medications. Seven patients were Pulse and blood pressure were monitored studied after nephrectomy. These anephric several times over the ensuing 10 min. After patients were normotensive without medica- 10 min in the tilted position, a second sition for blood pressure control when studied. multaneous pair of arterial and venous blood Patients in these two groups had normal samples were obtained. All blood samples were transferred to serum electrolytes and were considered heparinized tubes containing glutathione normovolemic. Two anephric, previously and other additives and immediately stored hypertensive, patients were available for in ice. The blood was separated in a refrigstudy before and after renal transplantation. All patients were studied under similar erated centrifuge (-4°C 4000 to 7000 rpm circumstances. Resting patients were trans- for 10 min), the plasma removed and imferred from their hospital bed, usually by mediately stored at -70°C. Samples were wheelchair, and transported to a quiet room analyzed in duplicate, usually within a few where they were transferred to a circle days, by single isotope radioenzymatic aselectric bed and allowed to rest supine for say [17]. TABLE

1

ARTERIALANDVENOUSPLASMACATECHOLAMINECONTENTRESTINGANDTILTVALUES" Resting (&liter)

Tilted @&liter)

Arterial

Venous

Arterial

Venous

Norepinephrine

0.416 1.105 0.943

0.256 0.851 1.143

0.272 1.405 1.671

0.306 0.408 1.301

Mean SD

0.821 0.360

0.750 0.452

1.116 0.743

0.672 0.547

Epinephrine

0.409 1.190 0.414

0.116 0.120 0.627

0.172 1.462 2.055

0.170 0.456 0.258

Mean SD

0.671 0.449

0.621 0.502

1.230 0.963

0.295 0.146

n End-stage renal failure hypertensive

patients requiring

nephrectomy

for blood pressure control.

350

JOURNAL

OF SURGICAL

RESEARCH: TABLE

VOL. 26, NO. 4, APRIL

1979

2

ARTERIAL AND VENOUS PLASMA CATECHOLAMINE CONTENT RESTING AND TILTED VALUES’ Resting (~p/liter) Arterial

Tilted @g/liter)

Venous

Arterial

Venous

Norepinephrine

0.284 0.223 0.304 0.436 0.315 0.113* 0.49ob

0.338 0.281 0.358 0.442 0.385 0.438* 0.945b

0.369 0.617 0.506 0.536 0.327 0.755* 0.3136

0.392 0.592 0.538 0.618 0.370 0.236b 0.38ob

Mean’ SD

0.312 0.077

0.361 0.059

0.471 0.120

0.502 0.114

Epinephrine

0.147 0.089 0.196 0.176 0.045 0.09ob 0.56Sb

0.160 0.125 0.260 0.094 0.050 0.513b 0.42jb

0.201 0.201 0.394 0.082 0.048 0.355b 0.250”

0.173 0.132 0.414 0.092 0.087 0.115b 0.27jb

Mean” SD

0.131 0.063

0.138 0.079

0.185 0.136

0.180 0.136

a End-stage renal failure, previously hypertensive patients, blood pressure controlled by bilateral nephrectomy. b Values not included in analysis as patients were agitated during study. c Mean values are greater (P < 0.05, Student’s t test) than previously reported values in normal man [18].

Results were grouped and analyzed for variance. Intergroup comparisons were made with Student’s t test and results were also compared to previously established normal values for this laboratory [ 181. RESULTS

Blood pressure and pulse did not show a consistent change in any group. No patients had signs or symptoms of hypotension during passive tilting. Two patients were clinically very anxious during the test and this psychic excitement was reflected in markedly elevated resting values for plasma norepinephrine and/or epinephrine (group 2). Group I: End-Stage Renal Failure Prior to Bilateral Nephrectomy (N = 3)

These patients were taking a variety of vasoactive antihypertensive drugs to control

severe hypertension. Aldomet, which causes a false positive reaction with the catecholamine assay, was excluded for a 3-week period prior to study in all patients. High resting levels of arterial and venous NE and E content were found (Table 1). In two of these three patients arterial NE and E content increased following tilting beyond the high resting levels with persistante of higher arterial than venous content. Group 2: End-Stage Renal Failure Patients Following Bilateral Nephrectomy (N = 5)

Seven patients were studied but two patients were deleted from analysis as they were extremely anxious during the testing procedure and were found to have resting and/or stimulated E or NE values far above the remainder of the study group (Table 2). Resting values for E and NE content were elevated in both arterial and venous blood

BADDER ET AL.: CATECHOLAMINE

RESPONSES TO ORTHOSTATIC

STIMULATION

35 1

TABLE 3 ARTERIAL AND VENOUS PLASMA CATECHOLAMINE CONTENT RESTING AND TILTED VALUES”

Tilted (&liter)

Resting &r/liter) Arterial

Venous

Arterial

Venous

Norepinephrine

0.276 0.090

0.138 0.126

0.364 0.184

0.268 0.094

Epinephrine

0.037 0.066

0.042 0.106

0.079 0.089

0.031 0.079

B Renal transplant recipients, previously hypertensive patients controlled by nephrectomy-normotensive after renal transplantation.

above previously reported normal values for this laboratory (P < 0.05) [18]. At rest, venous values for E and NE exceeded arterial in all instances except patient four who tended toward higher arterial than venous E (NE, P < 0.10; E, P > 0.10, Table 2). After stimulation by passive tilting, in four of five patients, venous NE content exceeded arterial levels but only three of five patients had stimulated venous E greater than arterial E (Table 2).

Stimulation by tilting suggested increased arterial NE (A 0.159 pg/liter, P < 0.10) in all five patients. Venous NE increased in four of five patients (A 0.141 pg/liter, P < 0.10). In four of five patients arterial E changed insignificantly with tilt (A O.OSS), as did venous E in four of five patients (A 0.042). Stimulated values for E and NE in both arterial venous samples were greater (P < 0.05) than stimulated values of normal

TABLE 4 PREVIOUS REPORTS OF RESTING AND TILTED VENOUS CATECHOLAMINE CONTENT

Norepinephrine Supine Fluorometric technique (&liter) M. Carruthers et al., 1970 [21] R. Hickler et al., 1959 [25] Young Old H. Weil-Malherb and A. Bone, 1954 [26] Radioenzymatic technique (&liter) E. Badder et al., 1977 [18] A. Silverburg et al., 1978 [27] C. Lake et al., 1977 [28] C. Lake et al., 1976 [29] C. Mathias et al., 1975 [30] R. Mueller et al., 1974 [31] P. Cryer et al., 1974 [32] N. Christensen, 1974 [23] P. Cryer et al., 1974 [33]

Tilted

0.79 2 4.7% 2.8 k 1.0 3.5 2 1.3

’ Patients standing, not passive body tilting.

Supine

Tilted

0.28 2 21.6% 5.1 2 1.3 5.2 rt 1.4

5.76 T 0.95 0.156 ? 0.228 L 0.304 + 0.292 k 0.13 0.261 ? 0.218 + 0.267 t 0.18 + 0.182 -t

Epinephrine

0.121 0.241 ? 0.163 0.081 0.020 A0.239 zk 0.022” 0.016 0.538 + 0.044” 0.28 0.050 AO.095 + 0.035 0.036 0.538 t 0.090” 0.036 0.06 0.021 0.425 k 0.028”

2.50 + 0.64 0.033 _f 0.021

0.03 0.020 0.046 0.043 0.06 0.044

k ‘k 2 +

0.048 2 0.023

0.04 0.005 AO.025 + 0.018 0.011 0.082 k O.Oly 0.005 0.07 0.011 0.073 2 0.017”

352

JOURNAL

OF SURGICAL

RESEARCH:

VOL. 26, NO. 4, APRIL

1979

of norepinephrine and epinephrine after tilting. He found norepinephrine excretion to increase approximately fourfold basal levels (16.5 2 4.7 ng/min resting to 55.8 * 7.5 ngl Group 3: Transplant Recipients Following Previous Bilateral Nephrectomy (N =2) min tilted) where as epinephrine excretion only increased from 4.8 -+ 1.4 ng/min to Following renal transplantation in two 7.3 -+ 1.5 @min. previously anephric patients, arterial and In this study, we anticipated depressed venous E contents were normal and were catecholamine response to the orthostatic little changed with tilting. NE content also stimulus in the anephric patients. Such a tended to be lower than in anephric patients result would be consistent with animal studies (Table 3). indicating renal support for adrenergic reflexes [l-6]. However, resting and stimuDISCUSSION lated values of both epinephrine and norepiPrior to the recent development of a highly nephrine exceeded previously reported E and accurate radioenzymatic assay for catechol- NE content in normal individuals for this amines [17, 193, precise determinations of laboratory and tend to be above values found plasma content of norepinephrine and epi- in other laboratories using a similar assay nephrine in small volumes were not available. (Table 4). These findings require explanaStudies of plasma catecholamines using tion. The study patients were previously sethe flurometric assay technique had suggested a higher plasma content of NE and E verely hypertensive and may not have northan recent experience would indicate (Table mal neurovascular responses [ 151.In addition, 4). Using the present assay, small changes augmented sympathetic activity may occur (0.010 pglliter) in circulating adrenergic in compensation for missing renal factors hormones may be detected, and improved which enhance vasomotor tone. This sugunderstanding of adrenergic release mecha- gestion is consistent with the notably innisms is possible. creased circulating epinephrine levels of the Plasma catecholamine content varies anephric patients (Table 2). While some widely with changes in activity, position, epinephrine is stored in peripheral tissues anxiety, blood volume, and plasma glucose for release with adrenergic stimulation as [3, 14, 18,20-241. When determined in quiet, seen in seven of our patients when brachial resting supine patients from repeated blood venous E content excedes arterial E content, specimens obtained through indwelling cath- most epinephrine is derived from the adrenal eters inserted prior to blood sampling, medulla [35,36]. Increased basal and stimuplasma catecholamine content is relatively lated plasma E contents indicate adrenal stable [21]. Previous studies suggest that medullary hypersecretion secondary to sympassive orthostatic tilting to 60” or greater pathetic nerve hyperactivity since in our increases venous plasma catecholamine patients there is no reason to suspect imcontent about 60% above resting levels paired tissue uptake of decreased catabolism (Table 4). Active standing provokes a some- of catechoiamines. what greater response to about twofold restOther hypotheses are possible. Patients in ing levels (Table 4). Most of the orthostat- the study group all required chronic hemoically stimulated increase in plasma cate- dialysis. Although electrolytes were within cholamine content has been in norepinephrine normal limits and patients were considered with less marked elevation of epinephrine normovolemic, they may have been chronicontent (Table 4). These plasma findings cally hypovolemic with their increased cirare consistent with the careful study of culating catecholamines reflecting a response Sundin [34] who measured urinary excretion to low blood volume. Against this theory subjects previously determined in this laboratory [ 181.

BADDER ET AL.: CATECHOLAMINE

RESPONSES TO ORTHOSTATIC

is the lack of hypotension during tilting in these patients, an anticipated finding in hypovolemic patients. Another possible explanation for the present results is loss of a sympathetic modulating agent elaborated by the kidney. In support of this theory are several studies pointing to a modulating influence of renal hormones on adrenergic activity and blood pressure control [S, 91. The recent report by Tan, ef al. [7] suggests a deficit of prostaglandin E, excretion in essential hypertension patients. Prostaglandin E, inhibits reflex norepinephrine release [36]. Absence of one source of PGE, in the anephric study group may permit increased reflex catecholamine release from the adrenal medulla and sympathetic neurons. Renal prostaglandin A is considered to moderate blood pressure and is also missing in anephric patients [S, 91. Both hypotheses of either a missing modulating factor in the anephric patient or a stimulus by hypovolemia are consistent with the return to normal E and NE content found after renal transplantation (Table 3). REFERENCES 1. Prager, R., Seaton, J., and Harrison, T. Reflex

2.

3. 4.

5. 6. 7.

8.

stimulation of peripheral norepinephrine release: Effect of nephrectomy and a physiological infusion of angiotensin II. Surg. Forum 26: 188, 1975. Tobian, L. Renin-angiotensin mechanisms in shock. In L. C. Mills and J. Moyer (Eds.), Shock and Hypotension. New York: Grune & Stratton, 1965. P. 347. Harrison, T., Birbari, A., and Seaton, J. Reinforcement of reflex epinephrine release by angiotensin II. Amer. J. Physiol. 224: 31, 1973. Jakschik, B., Marshall, G., Kourik, J., and Needleman, P. Profile of circulating vasoactive substances in hemorrhagic shock and their pharmacologic manipulation. J. Clin. Invest. 54: 842, 1974. Worcel, M., Moyer, P., d’Auriac, A., Papanicolau, N., and Milliez, P. The role of angiotensin. Circ. Res. 26/27(Suppl. II): 223, 1970. Regoli, D., Park, W., and Rioux, F. Pharmacology of angiotensin. Pharmacol. Rev. 26: 69, 1974. Tan, S., Sweet, P., and Mulrow, P. Impaired renal production of prostaglandin E,: A newly identified lesion in human essential hypertension. Prostaglandins 15: 139, 1978. Lee, J. The inter-relationships between renal pros-

STIMULATION

353

taglandins and blood pressure regulation. Amer. J. Med. Sci. 263: 335, 1972.

9. Lee, J. Hypertension, natriuresis and the renal prostaglandins. Ann. Intern. Med. 70: 1033, 1969. 10. Powell, J., and DuCharme, D. Effect of renal pressor systems on vascular capacity during hemorrhage. Amer. .I. Physiol. 226: 168, 1974. 11. DuCharme, D., and McCandlis, M. Evidence for a circulating vasoconstrictor substance of renal origin. Acfa Physiol. Lat. Amer. 24: 476, 1974. 12. Feuerstein, G., Boonyaviroj, P., and Gutman, Y. Renin-angiotensin mediation of adrenal catecholamine secretion induced by hemorrhage. Eur. J. Pharmacol.

44: 131, 1977.

13. Kaufman, J., Maxwell, M., Crown, J., and Okun, R. Hypertension-Primary and secondary. Ann. Intern. Med. 75: 761, 1971. 14. Gross, F. The renin-angiotensin system and hypertension. Ann. Intern. Med. 75: 777, 1971. 15. Linas, S., Miller, P., McDonald, K., Stables, D., Katz, F., Weil, R., and Schrier, R. Role of the renin-angiotensin system in post-transplantation hypertension in patients with multiple kidneys. N. Engl. J. Med. 298: 1440, 1978. 16. Srupada, T., Maris, T., Delano, B., and Friedman, E. Continuing high mobidity during maintenance hemodialysis consequent to bilateral nephrectomy. Amer. Sot. Artif. Intern. Organs 19: 340, 1973. 17. Peuler, J., and Johnson, G. Simultaneous single isotope radioenzymatic assay of plasma norepinephrine, epinephrine and dopamine. Life Sci. 21: 625, 1977. 18. Badder, E. M., Seaton, J., and Harrison, T. Arterial and venous catecholamine responses to passive orthostatic stimulation. Surg. Forum 28: 115, 1977. 19. Passon, P., and Peuler, J. A simplified radiomatic assay for plasma norepinephrine and epinephrine. Ann. Biochem. 51: 619, 1973. 20. Harrison, T., Seaton, J., and Bartlett, J. Adrenergic mechanisms in acute hypovolemia. Surg. Forum 17: 66, 1966. 21. Carruthers, M., Taggert, P., Conway, N., Bates, D., and Sommerville, W. Validity of plasma-catecholamine estimations. Lancet 2: 62, 1970. 22. Fluck, D., and Salter, C. Effect of tilting on plasma catecholamine levels in man. Cardiovasc. Res. 7: 823, 1973. 23. Christensen, N. Plasma norepinephrine and epinephrine in untreated diabetics during fasting and after insulin administration. Diabetes 23: 1, 1973. 24. Caniere, S., Lalumiere, G., Daigneault, A., and DeChamplain, J., Sequential changes in catecholamine plasma levels during isotonic volume expansion in dogs. Amer. J. Physiol. 235: Fl19, 1978. 25. Hickler, R., Hamhn, J., and Wells, R. Plasma norepinephrine response to tilting in essential hypertension. Circulation 20: 422, 1959. 26. Weil-Malherbe, H., and Bone, A. On the occur-

354

JOURNAL OF SURGICAL RESEARCH: VOL. 26, NO. 4, APRIL 1979

rence of adrenaline and noradrenaline in blood. Biochem. J. 58: 132, 1954. 27. Silverburg, A., Shah, S., Haymond, M., and Cryer, P. Norepinephrine: Hormone and neurotransmitter in man. Amer. J. Physiol. 243: E252, 1978. 28. Lake, C., Ziegler, M., Coleman, M., and Kopin, I. Age adjusted plasma norepinephrine levels in normotensive and hypertensive subjects. N. Engl. .I. Med. 2%: 208, 1977. 29. Lake, C., Ziegler, M., and Kopin, I. Use of plasma norepinephrine for evaluation of sympathetic neuronal function in man. Life Sci. 18: 1315, 1976. 30. Mathias, C., Christensen, N., Corbett, L., Frankel, H., Goodwin, T., and Pear& W. Plasma catecholamines, plasma renin activity and plasma aldosterone in tetraplagic man, horizontal and tilted. Clin. Sci. Mol. Med. 49: 291, 1975. 31. Mueller, R., Millward, D., and Woods, J. Circulating catecholamines plasma renin and dopamine-B hydroxylase activity with postural stress. Pharmacol. Biochem. Behav. 2: 757, 1974.

32. Cryer, P., Santiago, J., Shah, S., and Garber, A. Plasma norepinephrine and epinephrine determined by a sensitive simplified isotope derivative method. Clin. Res. 22: 465A, 1974. 33. Cryer, P., Santiago, J., and Shah, S. Measurement of norepinephrine and epinephrine in small volumes of human plasma by a single isotope derivative method: Response to upright posture. C/in. Endocrinol. Metabol. 39: 1025, 1974. 34. Sundin, T. The effect of body posture on the urinary excretion of adrenaline and noradrenaline. Acta Med. &and. 161(Suppl. 331-337): 1, 1958. 35. Pohorecky, L., and Wurtman, R. Adrenocortical control of epinephrine synthesis. Pharm. Rev. 23: 1, 1971. 36. Von Euler, U. S., Franksson, C., and Hellstrom, J. Adrenaline and noradrenaline output in urine after unilateral and bilateral adrenalectomy in man. Acta Physiol. Stand. 31: 1, 1954. 37. Hedquist, P. Basic mechanisms of prostaglandin action on autonomic neutrotransmission. Annu. Rev. Pharmacol. Toxicol. 17: 259, 1977.