News in sodium balance A. Tissue sodium in healthy and hypertensive patients B. Sodium sensing in the interstitium and relationship to hypertension.

Transcription

1 News in sodium balance A. Tissue sodium in healthy and hypertensive patients B. Sodium sensing in the interstitium and relationship to hypertension. Jens Titze Division of Clinical Pharmacology Vanderbilt University Interdisciplinary Center for Clinical Research University of Erlangen

2 Sodium VEGF-C balance vermittelte Regulation der - und Volumenhomöostase Assumption 1: Steady state: was goes in, must come out. Assumption 2: Body is accompanied by commensurate amounts of water. Assumption 3: Body content is maintained within narrow limits.

3 Isotonicity of the internal environment: the two-compartment model VEGF-C vermittelte Regulation der - und Volumenhomöostase ECV ICV K + K + K + K + K + K +

4 and VEGF-C maintenance vermittelte of internal Regulation environment der -composition und Volumenhomöostase Intake: Thirst 69 g NaCl ECV ICV Excretion: K + Skin K + 9 g NaCl Kidney ADH RAAS Nerves 140 mmol/l ( 9 g NaCl/L) K mmol/l

5 Sodium VEGF-C balance vermittelte Regulation der - und Volumenhomöostase What is the reverse experiment?

6 The Mars500 Project VEGF-C vermittelte Regulation der - und Volumenhomöostase The metabolic ward. Temp C Humidity: 40-75% Air Pressure: mmhg PCO 2 < 8 mmhg PO 2 : mmhg

7 A little help VEGF-C from vermittelte our friendsregulation der - und Volumenhomöostase

8 Acknowledgements VEGF-C vermittelte Regulation der - und Volumenhomöostase

9 Source: esa.com Doing the VEGF-C reverse vermittelte experiment: Regulation the Mars500 der -project und Volumenhomöostase Urinary recovery: 95% 95%

10 Doing the VEGF-C reverse vermittelte experiment: Regulation the Mars500 der -project und Volumenhomöostase Great! Let s go home!

11 The Mars500 Project Cell Metabolism 17: , 2013

12 The Mars500 Project: Value of an accurately UNaV sample Unpublished

13 The Mars500 Project: Does salt intake determine fluid intake? Unpublished

14 The Mars500 Project: Does salt intake influence fluid intake? Unpublished

15 The Mars500 Project: Dietary salt leads to urinary concentration. Unpublished

16 The Mars500 Project Where is the salt? Cell Metabolism 17: , 2013

17 1. Why VEGF-C do vermittelte we want Regulation to see der the - und Volumenhomöostase sodium? a) Because serum electrolytes do not tell us much about tissue electrolyte composition. b) Because immune cells seem to regulate interstitial electrolyte homeostasis, and because interstitial electrolytes may boost immune responses. c) Because tissue accumulation may be hidden disease entity.

18 23 Na MRI for detection of hidden storage in humans Signal 1,5 1 0,5 0 TE = 2 3 ms w Na = g Na B -0, t in ms Signal Einhüllende

19 Sodium storage and its coincidence with hypertension. Hypertension, 2013

20 Hypertension, 2013

21 Where is the salt? Hypertension, 2013

22 MRI (TE 2.07 ms) (mmol/l) mmhg Sodium storage and its coincidence with hypertension. 30 P (age) < 0.01 P (gender) < P (age) < 0.01 P (gender) < Women Men 0 Women Men DuoSet ELISA Development Kit R&D Systems Sandwich Elisa

23 Can we mobilize? Hypertension, 2013

24

25 storage in the interstitium: the three-compartment model VEGF-C vermittelte Regulation der - und Volumenhomöostase ECV ICV 1. Am J Kidney Dis, (3): Serum Interstitium 2. Am J Physiol Renal Physiol, (6): F K + K + 3. Am J Physiol Heart Circ Physiol, (1): H Am J Physiol Renal Physiol, (4): F Hypertension, (6): K + 6. Am J Physiol Renal Physiol, (5): F Am J Physiol Renal Physiol, : F Nat Med, (5): Hypertension, :

26 JCI, 2013; 123: Is the skin VEGF-C interstitium vermittelte hypertonic Regulation compared der - und to plasma? Volumenhomöostase Chemical analysis

27 storage in the interstitium: the three-compartment model VEGF-C vermittelte Regulation der - und Volumenhomöostase ECV ICV 1. Am J Kidney Dis, (3): Serum Interstitium 2. Am J Physiol Renal Physiol, (6): F K + K + 3. Am J Physiol Heart Circ Physiol, (1): H Am J Physiol Renal Physiol, (4): F Hypertension, (6): K + 6. Am J Physiol Renal Physiol, (5): F Am J Physiol Renal Physiol, : F Nat Med, (5): Hypertension, :

28 Ernest Henry Starling ( )

29 How is microcirulation organized? Traditional view (Starling, J Physiol, 19, , 1896) P (i) = - 2 P( ) = 0.1 P (i) = - 2 P( ) = 3 P (c) = 35 P( ) = 28 A P (eff) = 9 L P (eff) = 8 P (c) = 15 P( ) = 28 V

30 How is microcirulation organized - why not questioning Starling s equation? P (c) = 35 P( ) = 28 P(Na) 5000 A P (i) = - 2 P( ) = 0.1 P(Na) 5600 P (eff) = 9600 L + K mmol/l Osm 290 mosm/kg P(osmNa) 5000 mmhg P (i) = - 2 P( ) = 3 P(Na) K mmol/l 240 mmol/l Osm mosmol/kg P(osmNa) 5600 mmhg P (eff) =??? P (c) = 15 P( ) = 28 V

31 2. How VEGF-C can vermittelte we see Regulation the sodium? der - und Volumenhomöostase a) By chemical analysis (19th and 20th century). b) Invasively by EDX-SEM microscopy. c) Non-invasively by 23NaMRI (21th century).

32 VEGF-C vermittelte Regulation der - und Volumenhomöostase Sodium sensing in interstitium and Relationship to hypertension

33 S-S enos enos enos LSD HSD Blood: [ + K + ] 143 ± 2 mm 145 ± 2 mm Agnes Schröder Skin: [ + K + ] 177 ± 8*mM 191 ± 7 * mm LSD Anti-VEGF-C LSD HSD HSD Anti-ß Actin 50 µm 50 µm NO _ Cl - Ton EBP _ NO NO VEGFR-2 VEGF-C VEGFR-3 Blood Vessel Interstitium Lymph Hyperplastic VesselLymph Vessel Nature Medicine, 2009

34 Kidney Clearance 2 Blood Skin Interstitium S-S Clearance 1 enos enos NO NO Part 1 Ton EBP Cl - Na+ _ Lymph Vessel Cl - VEGFR-2 VEGF-C VEGFR-3 Part 2 Lymph Vessel Urine Cl -

35 VEGF-C vermittelte Regulation der - und Volumenhomöostase Questions: 1. MPS: regulators of electrolytes and blood pressure? 2. Lymphatic regulation of blood pressure? 3. Is blood pressure regulated in the skin?

36 JCI, 2013; 123: Macrophages regulate skin electrolyte homeostasis VEGF-C vermittelte Regulation der - und Volumenhomöostase and blood pressure A C 0.08 Skin chloride 0.08 mmol g DW mmol ml n = 2 n = 3 n = 2 n = 3 SKCl - SKCl - / SKW 0.00 B D FVB HSD LSD LysM wt/wt TonEBP flox/flox LysM wt/cre TonEBP flox/flox 500 µm 500 µm 500 µm

37 VEGF-C vermittelte Regulation der - und Volumenhomöostase Questions: 1. Is the skin microenvironment hypertonic? 2. Are lymph capillaries important for blood pressure? 3. Is skin VEGF-C important for blood pressure control?

38 S-S enos enos enos Lymphatic regulation of blood pressure? Agnes Schröder Bronek Pytowski NO Cl - Ton EBP NO HYPERPLASIA WITH VEGFR-3 BLOCKADE NO NO VEGFR-2 VEGF-C VEGFR-3 Blood Vessel Interstitium Lymph Vessel

39 JCI, 2013; 123: Lymphatic regulation of blood pressure? Experiments with mf4-31c1

40 Lymphatic regulation of blood pressure VEGF-C vermittelte Regulation der - und Volumenhomöostase JCI, 2013; 123:

41 JCI, 2013; 123: Lymphatic regulation of blood pressure Experiments with mf4-31c1 a b c MAP (mmhg) LSD LSD + mf4-31c1 HSD HSD + mf4-31c1 R 2 = Lymph capillary density (AU) rskcl - (mmol g DW -1 ) 0.06 R 2 = Lymph capillary density (AU) SKCl - / SKW(mmol ml -1 ) 0.06 R 2 = Lymph capillary density (AU)

42 VEGF-C vermittelte Regulation der - und Volumenhomöostase Questions: 1. Is the skin microenvironment hypertonic? 2. Are lymph capillaries important for blood pressure? 3. Is skin VEGF-C important for blood pressure control?

43 S-S enos Skin VEGF-C and blood pressure Agnes Schröder Kari Alitalo VEGFR-2 Ton EBP Cl - _ VEGFR-2 NO VEGF-C VEGFR-3

44 Skin VEGF-C and blood pressure JCI, 2013; 123:

45 Skin VEGF-C and blood pressure Does not seem to be a kidney problem.

46 JCI, 2013; 123: Skin VEGF-C and blood pressure Lymph Capillary Density wt LSD HSD * K14-FLT4 LSD HSD wt * K14-FLT SKCl - / SKW (mmol ml -1 ) MAP (mmhg) LSD HSD wt * K14-FLT4 LSD HSD wt K14-FLT Serum [Cl - ] (mmol L -1 )

47 Lymphatic regulation of blood pressure Model research sleep at the witch? Patient research

48 ESRD patients

49 MRI (TE 2.07 ms) (mmol/l) mmhg Sodium storage and its coincidence with hypertension. 30 P (age) < 0.01 P (gender) < P (age) < 0.01 P (gender) < Women Men 0 Women Men DuoSet ELISA Development Kit R&D Systems Sandwich Elisa

50 ESRD patients

51 ESRD patients Age

52 Kidney Clearance 2 Blood S-S Clearance 1 Skin Interstitium enos enos NO NO Ton EBP Cl - _ Lymph Vessel Cl - VEGFR-2 VEGF-C VEGFR-3 Lymph Vessel Urine Cl -

53 Sodium removal in ESRD patients A Pre-HD B C : 31.9 mmol/l Skin 23Na Muscle 23Na 40 P< P<0.001 Post-HD : 19.0 mmol/l mmol/l mmol/l Pre-HD Post-HD Pre-HD Post-HD

54 ESRD patients

55 Electrolyte VEGF-C vermittelte homeostasis: Regulation der - und Volumenhomöostase Immunology beyond innate and adaptive stereotypes Summary 1. Isotonicity versus hypertonicity. 2. Clearance. 3. What is immune function?

56 Junior Research Group II Agnes Schröder, PostDoc (biology) Diana Friedrich, PhD student (biology) Natalia Rakova, MD Peter Linz, PhD (physics) Anke Dahlmann, MD Christoph Kopp, MD Jennifer Goss (technician) Ulrike Goller (technician) Jonathan Jantsch Karl Hilgers Kai-Uwe Eckardt Bernd Sterzel Funded by: IZKF (TP B13, Junior Research Group 2) DFG (Ti-345/2, Lymphatics) DLR/BMBF Collaborators Andreas Hess, Erlangen Armin Kurtz, Regensburg Bronek Ptykowski, ImClone, New York Dominik Müller, Berlin Dontscho Kerjaschki, Vienna Franz-Xaver Beck, Munich Friedrich C. Luft, Berlin Hubertus Wagner, Kulmbach Katharina Machura, Regensburg Kari Alitalo, Helsinki Mark Belakovsky, Moscow Michael Deimling, Erlangen Michael Uder, Erlangen Moo Kwoon, Baltimore Nicola Volpi, Modena Peter Dietsch, Berlin Tuomas Tammela, Helsinki Wolfgang Neuhofer, Munich

57 Results: Sodium during Therapy Before Therapy (69.5 kg) (103 kg) (73.5 kg) After Therapy (65.7 kg) (100 kg) (70.4 kg)