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Aquaporins in brain: distribution, physiology, and pathophysiology.

Water homeostasis in the brain is of central physiologic and clinical importance. Neuronal activity and ion water homeostasis are inextricably coupled. For example, the clearance of K+ from areas of high neuronal activity is associated with a concomitant water flux. Furthermore, cerebral edema, a final common pathway of numerous neurologic diseases, including stroke, may rapidly become life threatening because of the rigid encasement of the brain. A water channel family, the aquaporins, facilitates water flux through the plasma membrane of many cell types. In rodent brain, several recent studies have demonstrated the presence of different types of aquaporins. Aquaporin 1 (AQP1) was detected on epithelial cells in the choroid plexus whereas AQP4, AQP5 and AQP9 were localized on astrocytes and ependymal cells. In rodent brain, AQP4 is present on astrocytic end-feet in contact with brain vessels, and AQP9 is found on astrocytic processes and cell bodies. In basal physiologic conditions, AQP4 and AQP9 appear to be implicated in brain homeostasis and in central plasma osmolarity regulation. Aquaporin 4 may also play a role in pathophysiologic conditions, as shown by the reduced edema formation observed after water intoxication and focal cerebral ischemia in AQP4-knockout mice. Furthermore, pathophysiologic conditions may modulate AQP4 and AQP9 expression. For example, AQP4 and AQP9 were shown to be upregulated after ischemia or after traumatic injuries. Taken together, these recent reports suggest that water homeostasis in the brain is maintained by regulatory processes that, by control of aquaporin expression and distribution, induce and organize water movements. Facilitation of these movements may contribute to the development of edema formation after acute cerebral insults such as ischemia or traumatic injury.

Animals↗

[Increased secretion of vasopressin and edema formation in high dosage methotrexate therapy].

During high-dose methotrexate therapy we recognized a significant increase in AVP secretion as it has previously been reported for other cytostatics. We observed an excessive augmentation of AVP excretion in 24 h urine in 9 patients receiving high-dose methotrexate combined with a considerable water retention. The pathomechanism is so far unknown. From experimental data it may be assumed that methotrexate alters directly the neurosecretory areas of the cerebrum as well as effects the distribution of body fluid volumes. The considerable risk of a water intoxication seems to be of highly clinical importance.

Arginine Vasopressin↗

Chronic poisoning by copper in tap water: I. Copper intoxications with predominantly gastointestinal symptoms.

Copper can induce acute and chronic intoxications in humans. Copper in tap water has caused a series of severe systemic diseases in Germany in recent years (copper induced liver cirrhosis). Besides cirrhosis, another type of disease with predominantly gastrointestinal symptoms has occurred which likewise appeared to be induced by copper in tap water. - In a retrospective investigation we looked for additional indications and proof that chronic copper poisoning has been the cause of the observed gastrointestinal diseases. All patients suffering from this type of disease had copper plumbing in their houses. - The patients (children and adults) suffered from nausea, vomiting, colic, and diarrhoea. In the group of infants, one refused formula milk (prepared with tap water) and the others suffered from persistent restlessness, unexplainable screaming (especially at night) and/or long lasting diaper rash. - We accept the diagnosis of chronic copper intoxication as the cause of the gastrointestinal symptoms when at least one of the following criteria were fulfilled: 1. first manifestation, remission and relapse of the disease depend on intake and a non-intake of water containing copper, respectively. 2. hypercupric state of the patients (i.e. pathological high concentrations of the non-ceruloplasmin-bound copper in serum and/or elevated copper levels in urine) 3. signs of systemic copper intoxication in the same patient 4. signs of systemic copper intoxication or hypercupric states in members of the patient s family or in his neighbourhood (non-relatives) - We found that the disease can even be caused by copper concentrations below the allowed concentration given by the German Guidelines for Drinking Water (Trinkwasserverordnung). - The data prove that copper in drinking water can cause gastrointestinal diseases and not only the better known systemic diseases (i.e. copper induced liver cirrhosis). Copper poisoning must be considered as a possible cause of chronic gastrointestinal diseases in those countries in which copper plumbing is common.

Adolescent↗

Nutritional aspects in ultra-endurance exercise.

PURPOSE OF REVIEW: Despite much current debate regarding central and peripheral neural mechanisms which may be responsible for the onset of fatigue during prolonged exercise, maintenance of nutritional and hydration status remains critical for successful participation in ultra-endurance exercise. This review focuses on substrate and fluid homeostasis during ultra-endurance exercise and the use of nutritional supplementation both as ergogenic aid and to attenuate exercise-induced immunosuppression. RECENT FINDINGS: Current evidence continues to support mandatory high carbohydrate intakes (1). before the event to maximize muscle glycogen stores, (2). during the event to prevent hypoglycaemia and (3). after the event to optimize post-event repletion of endogenous carbohydrate stores. No consistent performance benefit has yet been shown following a high-fat diet. Greater utilization of intrafascicular triglyceride stores appears to account for additional fat utilization in females. Recent trends towards excessive fluid intake have resulted in frequent reports of hyponatraemic hyperhydration in ultra-distance athletes, with greater incidence in women than in men. Carbohydrate supplementation during the event attenuates immunosuppressive hormonal and cytokine responses to ultra-endurance exercise, but may impair vitamin C absorption, while the ergogenic value of caffeine supplementation in ultra-endurance performance is currently being questioned. SUMMARY: Meeting macronutrient and fluid intake demands remains an important priority for ultra-endurance athletes. Yet these athletes are reported to present with a high incidence of disordered eating patterns during periods of training, and excessive fluid replacement strategies have resulted in an increased incidence of water intoxication with resultant central nervous system dysfunction.

Dietary Carbohydrates↗

New insights into water transport and edema in the central nervous system from phenotype analysis of aquaporin-4 null mice.

Aquaporin-4 (AQP4) is the major water channel in the CNS. Its expression at fluid-tissue barriers (blood-brain and brain-cerebrospinal fluid barriers) throughout the brain and spinal cord suggests a role in water transport under normal and pathological conditions. Phenotype studies of transgenic mice lacking AQP4 have provided evidence for a role of AQP4 in cerebral water balance and neural signal transduction. Primary cultures of astrocytes from AQP4-null mice have greatly reduced osmotic water permeability compared with wild-type astrocytes, indicating that AQP4 is the principal water channel in these cells. AQP4-null mice have reduced brain swelling and improved neurological outcome following water intoxication and focal cerebral ischemia, establishing a role of AQP4 in the development of cytotoxic (cellular) cerebral edema. In contrast, brain swelling and clinical outcome are worse in AQP4-null mice in models of vasogenic (fluid leak) edema caused by freeze-injury and brain tumor, probably due to impaired AQP4-dependent brain water clearance. AQP4-null mice also have markedly reduced acoustic brainstem response potentials and significantly increased seizure threshold in response to chemical convulsants, implicating AQP4 in modulation of neural signal transduction. Pharmacological modulation of AQP4 function may thus provide a novel therapeutic strategy for the treatment of stroke, tumor-associated edema, epilepsy, traumatic brain injury, and other disorders of the CNS associated with altered brain water balance.

Animals↗

Dipsogenic diabetes insipidus: report of a novel treatment strategy and literature review.

Dipsogenic diabetes insipidus is a syndrome of disordered thirst, in patients without psychiatric disease, which may be confused with partial central diabetes insipidus. Distinguishing these entities involves monitored water testing. Therapy with antidiuretic hormone in patients with dipsogenic diabetes insipidus is thought to be contraindicated for fear of inducing water intoxication. We report a case of a 26-year-old woman without psychiatric illness referred for longstanding polyuria and polydipsia. Otherwise healthy, she complained of near-constant thirst and frequent urination, causing severe disruption of her personal and professional life. She had been consistently eunatremic and polyuric, with low urine osmolality. Results of extensive water testing revealed intact urinary concentrating and diluting capacity, physiologic though blunted antidiuretic hormone (ADH) release, and an abnormally low thirst threshold, consistent with the diagnosis of dipsogenic diabetes insipidus. To control her polyuria we initiated treatment with intermittent, low-dose, intranasal desmopressin and strict water restriction during drug dosing. In follow-up she reported excellent control of polyuria and significant functional improvement. The reviewed literature demonstrates a limited number of reports about dipsogenic diabetes insipidus, and no prior report of a similar treatment strategy. Dipsogenic diabetes insipidus is an uncommonly (and not universally) recognized disorder, requiring monitored testing in order to distinguish it from incomplete forms of central diabetes insipidus. Though therapy with desmopressin cannot be recommended based on the results of a single case, the outcome presented here is intriguing and suggests that larger studies in such patients is warranted to assess the broader application of such an intervention.

Adult↗

Fluid balance in ruminants: adaptation to external and internal challenges.

Ruminants are widespread in hot, arid regions. This demands adaptation to large circadian temperature fluctuations and recurrent periods of food and water shortage. Pregnancy and lactation add to the demands on the adaptive mechanisms due to the greater need for food, water, and electrolytes. The blood volume increases to meet the requirements of the fetoplacental unit and the mammary glands. Unlike urine, the milk cannot be concentrated by antidiuretic hormone (vasopressin). During water deprivation, lactating animals therefore become dehydrated more rapidly than nonlactating animals. Nevertheless, desert-adapted lactating ruminants endure frequent periods of water deprivation without incurring bad health. For the offspring living in hot and dry conditions, it is an advantage that the milk is not concentrated, even if the mother has a high antidiuretic hormone concentration to enable her to concentrate the urine. Since ruminants are prey, they need to drink rapidly when they get access to water. The forestomach allows the animals to store water in the reticulorumen. There is no danger of water intoxication even if they drink to satisfaction in a couple of minutes after having lost as much as 30% of their body weight.

Acclimatization↗

The danger of an inadequate water intake during prolonged exercise. A novel concept re-visited.

To prevent thermal injuries during distance running, the American College of Sports Medicine proposes that between 0.83 and 1.65 l of water should be ingested each hour during prolonged exercise. Yet such high rates of fluid intake have been reported to cause water intoxication. To establish the freely-chosen rates of fluid intake during prolonged competitive exercise, we measured fluid intake during, body weight before and after, and rectal temperature after competition in a total of 102 runners and 91 canoeists competing in events lasting from 170-340 min. Fluid intakes during competition ranged from 0.29-0.62 l.h-1; rates of water loss ranged from 0.69-1.27 l.h-1 in the runners; values were lower in the canoeists. Mean post-race rectal temperatures ranged from 38.0-39.0 degrees C. There was no relationship between the degree of dehydration and post-race rectal temperature. We conclude that hyperthermia is uncommon in prolonged competitive events held in mild environmental conditions, and that exercise intensity, not the level of dehydration, is probably the most important factor determining the postexercise rectal temperature. During prolonged exercise in mild environmental conditions, a fluid intake of 0.5 l.h-1 will prevent significant dehydration in the majority of athletes.

Adolescent↗

Peak rates of diuresis in healthy humans during oral fluid overload.

OBJECTIVE: To determine whether rates of intestinal fluid absorption and renal diuresis can match high rates of fluid ingestion in healthy humans exposed to oral fluid overload, thereby preventing the development of hyponatraemia either by reverse sodium movement across the intestine (the Priestley-Haldane effect) or by expansion of the extracellular fluid volume. METHODS: Changes in renal function and in plasma chemical measurements in response to an oral fluid overload (0.9-1.8 l/h x 3 h) were investigated in 6 healthy control subjects at rest, and in a subject with a history of exercise-induced symptomatic hyponatraemia, during both prolonged (160-minute) exercise and at rest. FINDINGS: All control subjects gained weight (2.7 +/- 0.2 kg, mean +/- standard error of mean (SEM)) because the rate of oral fluid intake exceeded the peak rate of urine production (778 +/- 39 ml/h). Blood volume rose by 7.1 (+/- 0.5)% and plasma sodium concentrations fell progressively from 144 +/- 2.6 to 136 +/- 1.1 mmol/l (P < 0.05) in the control subjects. Plasma potassium and angiotensin II concentrations were unchanged and creatinine clearance was normal (approximately 125 ml/min). Free water clearance reached a maximum of 11.2 +/- 0.9 ml/min after 2 hours. The increase in body mass could be accounted for by calculated or measured changes in extra- and intracellular fluid volumes. Similar changes were measured in the subject with a previous history of symptomatic hyponatraemia. CONCLUSION: The rate of intestinal fluid absorption appeared to match the rate of oral fluid ingestion and there was no evidence of fluid accumulation in the intestine with reverse sodium movement from the extracellular space into intestinal fluid. The results of this study are therefore at variance with the Priestley-Haldane hypothesis and suggest that reverse sodium movement did not contribute to the hyponatraemia induced by oral fluid overload in these subjects. Rather it appears that humans may have a limited capacity to excrete fluid at rates in excess of approximately 900 ml/h in response to higher rates of oral fluid intake. When the rate of intestinal fluid absorption matches the rate of fluid ingestion and exceeds the kidneys' maximum capacity for fluid excretion, the excess fluid accumulates in the extra- and intracellular fluid compartments, inducing the dilutional hyponatraemia of water intoxication. These findings may have relevance to other clinical conditions in which hyponatraemia develops in response to high rates of oral or intravenous fluid provision.

Adult↗

Effect of chronic treatment with haloperidol on vasopressin release and behavioral changes by osmotic stimulation of the supraoptic nucleus.

Chronic treatment with dopamine D2 blockers in schizophrenic patients has been proposed as one of the causes of polydipsia and water intoxication, but this conclusion is still controversial. To investigate the relationship between dopamine D2 blockers and these syndromes, we designed a behavioral and neurochemical study using hyperosmotic stimulation in the supraoptic nucleus (SON) by microdialysis after chronic treatment with haloperidol in rats. Animals were injected with haloperidol decanoate (20 mg/kg, i.m.) or sesame oil at 2-week intervals for 8 successive weeks. During the 7th week, water-intake was increased 30-60 min after the hyperosmotic stimulation in both groups, but more so in haloperidol-treated animals compared to that in the control group. Moreover, arginine vasopressin (AVP) was released by the hyperosmotic stimulation in SON, but was not significantly different between groups. In addition, striatal dopamine levels 3-4 days after the microdialysis study showed a significant decrease in the haloperidol-treated animals. These results suggest that chronic treatment with haloperidol enhances water-intake produced by hyperosmotic stimulation in the SON but does not increase AVP levels in dialysates following hyperosmotic stimulation. Thus, these symptoms may be mediated by dopaminergic systems in brain.

Animals↗

Absorption of irrigating fluid during transcervical resection of endometrium--a report of two cases.

It has been recognized for many years that the use of hypotonic solution for the irrigation of the bladder cavity during transurethral resection of the prostate (TURP) may result in hyponatremia and water intoxication due to rapid and excessive absorption of the solution from the exposed prostatic bed, the clinical manifestation of which is termed "TURP syndrome". A similar condition termed "female TURP syndrome" following hysteroscopic transcervical endometrial resection (TCR) has been reported. Since the frequency of TCR continues to increase the increased rate of "TCR syndrome" would come in its wake. Here, we present two cases who developed severe hyperglycemia and hyponatremia while underwent TCR with 10% dextrose in water as the irrigation fluid and the same time emphasize the potential risk of this complication.

Adult↗

Alcoholic brain damage and neurological symptoms of alcohol withdrawal--manifestations of overhydration.

Central nervous system damage is a major complication of alcohol abuse. Vitamin deficiency, particularly thiamine deficiency, has a role in producing pathological and psychological changes of alcoholic brain damage, but it is likely that alcohol has a direct toxic effect on the brain. It is proposed that neuropathological abnormalities seen in alcoholics, and also neurological symptoms during alcohol withdrawal, may reflect cerebral edema caused by alcohol. The neurological symptoms of alcohol withdrawal show a similarity to those seen in hyponatremia or water intoxication. It is suggested that alcoholics show overhydration particularly during withdrawal and that pathological changes in the alcoholic brain are related to cerebral edema. Cerebral edema in withdrawing alcoholics may be caused by inappropriate section of vasopressin (antidiuretic hormone).

Alcoholism↗

Increased seizure threshold in mice lacking aquaporin-4 water channels.

Mice deficient in the glial water channel aquaporin-4 (AQP4) show decreased cerebral edema and improved neurological outcome following water intoxication or ischemic challenge. In this report, we tested seizure susceptibility in AQP4 mice. AQP4 mice and wild-type controls were given the chemoconvulsant pentylenetetrazol (PTZ) and monitored for seizure activity. At 40 mg/kg PTZ, all wild-type mice exhibited seizure activity, whereas six of seven AQP4 mice did not exhibit seizure activity. At 50 mg/kg PTZ, both groups exhibited seizure activity; however, the latency to generalized (tonic-clonic) seizures was significantly lower in wild-type than AQP4 mice. These results suggest that glial water channels may modulate brain excitability and the initiation and generalization of seizure activity.

Action Potentials↗

[Severe complications and mortality in mental eating disorders in adolescence. On 99 hospitalized patients].

BACKGROUND: Subclinical medical complications frequently occur during the follow-up of anorexia nervosa and bulimia. This paper describes some of these. POPULATION AND METHODS: Charts of 99 adolescent patients (89 girls and 10 boys), aged 11.8 to 22 years (mean: 16.6 +/- 2.1 years), admitted for anorexia nervosa (N:92) or bulimia (N:7), were analyzed retrospectively. All severe or potentially severe, clinical and non-clinical, findings at admission were included in the study. RESULTS: Anorexic patients had a mean weight loss of 31.5% (22 of them were also vomiters or laxative abusers). Initial nasogastric tube feeding was necessary in 19 patients and parenteral nutrition in 2. Bradycardia and hypotension were common. A variety of ECG abnormalities were seen in 86% of the patients. Mitral valve prolapse was present in 14 of the 43 patients examined by echocardiography. Electrolyte imbalance was also common: hyponatremia in 7 patients, hypokalemia in 21, hypochloremia in 10 of the 12 vomiters, hypophosphatemia in 7, hyperazotemia in 24 and hypoglycemia in 22. Bone marrow hypoplasia was frequent, with leukopenia in 29 patients, anemia in 21 and thrombocytopenia in 5. No patient developed infectious complications. One patient presented with an acute gastric dilatation and another with spontaneous pneumomediastinum. One patient, 14 year-old, died 3 years after the onset of anorexia from acute water intoxication. CONCLUSION: These well-known complications are more common in anorexic than in bulimic patients. Their prevention requires rigorous and continuous medical supervision.

Adolescent↗

Hyponatremia-associated rhabdomyolysis.

BACKGROUND: Hyponatremia is the most frequent electrolyte disorder. However, hyponatremia rarely results from excessive water intake, unless the kidney is unable to excrete free water, such as in patients on thiazide diuretics; in addition, hyponatremia is an uncommon cause of rhabdomyolysis. METHODS: We present a 51-year-old hypertensive woman on chronic hydrochlorothiazide therapy who developed acute water intoxication and severe myalgias. RESULTS: The patient developed acute hypotonic hyponatremia and subsequent rhabdomyolysis. We discuss the mechanisms responsible for the development of hyponatremia and its association with rhabdomyolysis. CONCLUSION: Muscle enzymes should be monitored in patients with acute hyponatremia who develop muscle pain, and hyponatremia-induced rhabdomyolysis must be considered in patients with myalgias receiving thiazide diuretics.

Benzothiadiazines↗

Alterations in electrical and mechanical activity in Langendorff-perfused guinea pig hearts exposed to decreased external sodium concentration with or without hypotonic insult.

In order to examine electrical and mechanical effects of hyponatremia and hypotonicity, relevant to those in patients with 'water intoxication' syndrome, Langendorff-perfused guinea pig hearts were exposed to reduced NaCl concentrations (hypotonic [NaCl](0)-reduction) under the monitoring of left ventricular developed pressure (LVDP) and epicardial ECG. In some hearts, hyponatremia (from 140 to 80 mEq/l) was compensated for by adding mannitol to maintain osmolarity at a constant level (isotonic [NaCl](0)-reduction) or tetraethylammonium chloride to maintain both osmolarity and chloride concentrations at a constant level (isotonic [Na(+)](0)-reduction). Progressive isotonic [NaCl](0)-reduction increased LVDP, which was abolished in the presence of KB-R7943, a novel inhibitor of Na(+)/Ca(2+)-exchange. LVDP was reduced in hypotonic [NaCl](0)-reduction in which myocardial water content was increased. PQ interval and QRS duration were prolonged with both hypotonic and isotonic [NaCl](0)-reduction and these changes tended to be more pronounced with hypotonic than with isotonic [NaCl](0)-reduction. Similar ECG changes were also evident with isotonic [Na(+)](0)-reduction. Gd(3+) (1-5 µM), a blocker of stretch-activated nonspecific cation channels, had no substantial effects on the electrical or mechanical changes seen with hypotonic [NaCl](0)-reduction. In conclusion, isotonic [NaCl](0)-reduction produced a positive inotropism by modulating Na(+)/Ca(2+)-exchange, whereas hypotonic [NaCl](0)-reduction led to negative inotropism, due in part to hypotonic myocardial swelling. In addition, [Na(+)](0)-reduction, irrespective of the concomitant [Cl(-)](0) or osmotic changes, depressed atrioventricular as well as intraventricular conduction.

Journal Article↗

Management of salt poisoning in an extremely low birth weight infant.

We present the first reported case of severe salt poisoning in an extremely low birth weight neonate. The salt poisoning was managed with the careful use of intravenous fluids, insulin to manage the severe hyperglycemia, and furosemide to induce a saline diuresis. The hypertonicity was normalized slowly over 3 days by following the corrected serum sodium (Na) (serum Na + 2.7 mEq for every 100 mg/dl of glucose over 100). No neurological damage was seen in our patient during the development of the hypertonicity or its correction. This suggests that the premature brain can develop osmoprotective molecules if hypertonicity develops slowly over 2-3 days. Slow correction is therefore recommended to avoid the development of water intoxication during correction. Despite the development of mild reversible renal failure, a large saline diuresis was induced with furosemide, thereby avoiding the need for dialysis in our patient. The only complication was the development of necrotizing enterocolitis, which has not been previously reported in association with salt poisoning.

Drug Overdose↗

[Paroxysmal hemoglobinuria in calves and its effect on hematologic and acid-base profiles].

Water intoxication is considered to be one of the possible causes of haemoglobinuria in calves. As to predisposing factors, prognosis and particularly differential diagnosis, uncertainty is rather frequent. Therefore we tried to provoke this state in an experiment, in which the disiony-induced changes of the acid-base balance (pH, pCO2, HCO3, pO2, BE, SAT of venous blood) were determined in addition to clinical observations (general behaviour, respiratory and pulse rates, body temperatures) and blood analysis (red and white blood cells, PCV and haemoglobin). Experimental paroxysmal haemoglobinuria was induced in eight 2-months-old male calves of the Black Pied breed weighing 55-70 kg that were held on a green diet. After the animals had been given cold water (12-14 degrees C) at an amount of 12% of their body weight, increased volume of the abdominal cavity, muscle tremor, and a stooping posture could be seen, and in 45-60 min. following water administration the first spontaneous haemoglobinuria occurred. Except the first 20 minutes following water gavage, when pronounced tachycardia accompanied by arythmia (100-130 per min.) was recorded, a tendency towards hypothermy, mild bradycardia and bradypnoe was observed; correction of these values occurred within 24 hours. Haematological indices revealed a hydraemic trend that was most pronounced and long-lasting in haemoglobin. Twenty-four hours after water gavage haemoglobin, red blood cells and PCV values were still below their starting levels; the tendency toward leucopoenia changed into leucocytosis. The acid-base balance revealed a slight acidemic trend with decreasing pH, actual bicarbonate and BE levels in the first hour; later, equilibration and increase within the physiological range occurred.(ABSTRACT TRUNCATED AT 250 WORDS)

Acid-Base Equilibrium↗