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Development of an Animal Model of Nephrocalcinosis Via Selective Dietary Sodium and Chloride Depletion

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Development of an Animal Model of Nephrocalcinosis Via Selective Dietary Sodium and Chloride Depletion nature publishing group Articles Translational Investigation Development of an animal model of nephrocalcinosis via selective dietary sodium and chloride depletion Shamir Tuchman1,2, Laureano D. Asico2, Crisanto Escano2, Daniel A. Bobb3 and Patricio E. Ray1,2 BACKGROUND: Nephrocalcinosis (NC) is an important tubulopathies, and in children with CLD (8–11). Hypercalciuria ­clinical problem seen in critically ill preterm neonates treated (HC) has not been a necessarily consistent finding in all infants with loop diuretics. No reliable animal models are available to with NC (12,13) and is also not typically present in children study the pathogenesis of NC in preterm infants. The purpose with CLD (8), which speaks to the nonessential role of HC in of this study was to develop a reproducible and clinically rel- the pathogenesis of this disease. NC does not uniformly resolve evant animal model of NC for these patients and to explore the in infants who are taken off loop diuretic therapy and certainly impact of extracellular fluid (ECF) volume contraction induced persists in children with inherited tubulopathies and CLD by sodium and chloride depletion in this process. (9,14,15). Furthermore, the ability of loop diuretics to promote METHODS: Three-week-old weanling Sprague-Dawley rats NC in preterm infants does not seem to result from an increase were fed diets deficient in either chloride or sodium or both. in stone-promoting substances such as oxalate (16). A subgroup of rats from each dietary group was injected daily Currently, no animal models exist that attempt to replicate with furosemide (40 mg/kg i.p.). the fluid and electrolyte abnormalities that are associated with RESULTS: Rats fed a control diet, with or without furosemide, the development of NC in the preterm infant. A previous model or a chloride-depleted diet alone, did not develop NC. By con- using i.p. furosemide alone in weanling rats on a control diet trast, 50% of the rats injected with furosemide and fed the chlo- was able to induce NC (17); however, these changes could not ride-depleted diet developed NC. Moreover, 94% of the rats fed be reproduced in our preliminary experiments. In addition, the combined sodium- and chloride-depleted diet developed furosemide has not been shown to induce NC in adult rats fed NC, independently of furosemide use. NC was associated with control diets (18). the development of severe ECF volume contraction; hypochlo- Other studies in adult rats have produced NC using a combina- remic, hypokalemic, metabolic alkalosis; increased phosphatu- tion of chloride depletion with either phosphate loading or high- ria; and growth retardation. sulfate diet (18,19). Isolated phosphate loading has consistently CONCLUSION: Severe ECF volume contraction induced by produced NC only in young rats (20). Therefore, the purpose chronic sodium and chloride depletion appears to play an of the current study was to develop a reliable and reproducible important role in the pathogenesis of NC. animal model system of NC that mimics the pathophysiological alterations associated with the development of NC in preterm ephrocalcinosis (NC) is a well-described complication seen neonates receiving furosemide, children with inherited renal Nfrequently in preterm infants and in older children with tubulopathies, or children with extrarenal losses of volume and inherited and acquired renal tubulopathies. Furthermore, NC electrolytes such as those that occur in CLD or pyloric stenosis. is a well-described complication of congenital chloride diarrhea (CLD), which, with time, contributes to the renal injury observed RESULTS in these patients (1). The pathogenesis of NC in preterm neo- Chloride- and Sodium-Deficient Diets Induced NC in Young Rats nates has been associated with the use of chronic loop diuretics, The most remarkable finding was that almost all rats that were as well as with the presence of electrolyte changes or critical ill- fed the combined sodium and chloride-deficient diet developed ness (2,3). However, the basic pathogenic mechanisms involved moderate to severe NC (P value < 0.001 as compared with con- in NC are not clearly understood, and there has been no defini- trols) (Table 1). Representative histologic samples from these tive link between the development of NC in preterm neonates groups and controls are shown in Figure 1. Young rats treated and the duration or dose of loop diuretic therapy. Estimates of with furosemide alone, or fed a selective chloride-deficient the incidence of NC on the basis of screening of preterm infants diet alone, developed hypokalemic, hypochloremic, meta- range from 7% to 39% (4–7). NC has been associated with the bolic alkalosis, but these changes were not sufficient to induce development of renal insufficiency and hypertension in preterm NC (Table 1). However, 50% of the chloride-depleted rats neonates treated with furosemide, in infants with inherited renal treated with i.p. furosemide developed moderate to severe NC 1Division of Pediatric Nephrology, Children’s Research Institute, Children’s National Medical Center, Washington, DC; 2Center for Molecular Physiology, Children’s Research Institute, Children’s National Medical Center, Washington, DC; 3Research Animal Facility, Children’s Research Institute, Children’s National Medical Center, Washington, DC. ­Correspondence: Shamir Tuchman ([email protected]) Received 24 February 2012; accepted 11 October 2012; advance online publication 16 January 2013. doi:10.1038/pr.2012.172 194 Pediatric RESEArCH Volume 73 | Number 2 | February 2013 Copyright © 2013 International Pediatric Research Foundation, Inc. Nephrocalcinosis via Na+/Cl− depletion Articles ab phosphate. None of rats that were fed a control diet devel- oped NC. NC Induced Through Severe ECF Volume Contraction Rats that developed severe extracellular fluid (ECF) volume contraction, as evidenced by decreased weight, increased hematocrit, and increased blood urea nitrogen, were more 100 µm likely to develop NC (Table 3). However, selective chloride- deficient rats developed significant ECF volume contraction cd but did not develop NC. These findings suggest that the ECF volume contraction per se is not sufficient to induce NC. Rats fed a low-sodium/chloride diet had a higher mean urine out- put (ml/d) (P < 0.05) than rats fed a control diet (Table 3). In the context of ECF volume contraction, this represents inap- propriate urinary fluid losses. Rats that were administered i.p. furosemide with either a low-chloride or low-sodium and low- chloride diet did not have a higher daily urine output than rats ef that were given the respective diets alone (Table 3). Urine Calcium Excretion in Rats With NC As shown in Figure 2, rats from dietary intervention groups (e.g., low-chloride diet + furosemide or low-sodium and low- chloride diet alone) that developed NC had mean urine cal- cium to creatinine ratios that were not different from those in animals fed a control diet. Across all dietary intervention groups, rats that developed NC had a significantly lower urine Figure 1. von Kossa and Alizarin red stains of kidney sections from calcium to creatinine excretion ratio (0.22 vs. 0.31 mg/mg Sprague-Dawley rats. The panel depicts (a) von Kossa and (b) Alizarin creatinine, P < 0.05) than those that did not. This relation- red staining from rats fed a control diet; (c) von Kossa and (d) Alizarin red ship also held true within the group of rats fed a low-chloride staining from rats fed a low chloride diet + i.p. furosemide; and (e) von diet and given i.p. furosemide in which 50% of animals devel- Kossa and (f) Alizarin red staining from rats fed a low-sodium and low- chloride diet. All panels represent ×25 original magnification. oped NC. Among this group, urine calcium excretion was sig- nificantly lower in rats that developed NC (0.18 vs. 0.29 mg/ Table 1. Occurrence of NC by dietary intervention group mg creatinine, P < 0.05). Across all study groups, the ionized calcium (mean ± SD) was 1.13 ± 0.11 among rats with NC Mild NC Moderate NC Severe NC n (category 1) (category 2–3) (category 4–5) and 1.26 ± 0.12 in rats without NC (P < 0.001). A decreased whole-blood ionized calcium level was associated with a Control 7 0 0 0 hypochloremic, hypokalemic, metabolic alkalosis in all rats (With/furosemide) 6 0 0 0 (Table 2). In a logistic regression model examining urinary Low chloride 11 0 0 0 parameters associated with NC, a lower urinary potassium (With/furosemide) 12 1 (8%) 3 (25%) 2 (17%) excretion (β-coefficient (β) = −3.8,P < 0.01) and a higher 24-h Low sodium/ 18 0 3 (17%) 14 (78%) urine output (β = 0.02, P = 0.05) were also associated with the chloride development of NC. (With/furosemide) 12 0 3 (25%) 9 (75%) NC, nephrocalcinosis. Association of Urine Phosphorus Excretion With NC As shown in Table 2, urinary phosphorus excretion was more than twofold higher among rats fed a low-sodium and low- (P value < 0.01). These changes were also associated with the chloride diet as compared with controls. In addition, among development of hyponatremia and decreased urinary sodium rats fed a low-chloride diet and were administered i.p. furo- excretion (Table 2). In general, animals that developed more semide, those that did develop NC had a 10-fold higher uri- severe metabolic alkalosis (e.g., higher serum bicarbonate con- nary phosphorus excretion than those that did not (P < 0.05). centration) also showed lower levels of ionized calcium. The lowest urine phosphorus excretion was seen among rats Examination of rat kidney sections stained with von Kossa fed a low-chloride diet alone, speaking against the notion that and hematoxylin and eosin (data not shown) under polar- increased urine phosphorus excretion resulted directly from ized light failed to reveal birefringent crystals in animals with chloride depletion.
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