R ecently, there has been increasing evidence supporting the efficacy and safety of the arginine vasopressin (AVP) type 2 (V 2 ) antagonist tolvaptan (TLV) in the improvement of hyponatremia or amelioration of congestion sparing renal function in acute/chronic heart failure (HF) patients refractory to considerable amounts of loop diuretics.
1)However, such a clinical benefit of TLV-incorporated diuretic therapy is not necessarily observed in all HF patients. In other words, we sometimes experience non-responders to TLV, whose clinical course worsens regardless of the initiation of TLV.
2)Although the precise mechanism of resistance to TLV is unknown, we previously speculated that aging and chronic kidney disease (CKD) were major risk factors of non-responders.3) In fact, concentrating and diluting ability in the collecting ducts is essential for the efficacy of TLV, but is often impaired in elderly or those with advanced CKD. However, according to our clinical experience, there were several responders to TLV even though they were complicated with stage G4 CKD.
Article p.533The efficacy of TLV treatment in patients with CKD is controversial. Sato, et al demonstrated in a recent study that some responders with diabetes mellitus nephropathy received a clinical benefit from TLV treatment even though their renal dysfunction was approximately equivalent to stage G4 CKD (22.1 ± 18.1 mL/minute/1.73m 2 of estimated glomerular filtration ratio). 4) Among the 8 patients from whom renal specimens were obtained, 7 were responders and simultaneously had explicit expression of aquaporin-2 (AQP2) in the collecting ducts. The remaining patient was a non-responder showing no expression of AQP2 with histological evidence of tubulointerstitial damage. Although the sample number was very small, they speculated that some, albeit not all, patients with advanced CKD did respond to TLV, and that the responses to TLV might be dependent on residual expression of AQP2 in the collecting ducts.AQP2 is the recently characterized AVP-regulated water channel expressed in the collecting ducts in the kidney.5,6) Secreted AVP from the pituitary gland binds to V 2 receptors located in the basolateral membrane of principal cells in the collecting ducts, and then the activated V 2 receptors trigger the transport of AQP2 from intracellular storage vesicles into the apical membrane. The amount of AQP2 activated determines the water permeability in the apical membrane and then dominates urinary concentrating ability. 7) Expression of AQP2 in the apical membrane is considered as an index of the V2-receptor dependent activity of the collecting ducts, which may be essential for the response to TLV because TLV cannot block water-reabsorption there without baseline expression or activation of AQP2 protein.Considering the above mechanism, AQP2 can be a good marker for predicting responses to TLV especially in patients with CKD. However, how can we measure the expression of AQP2 in the human kidney? Sato, et al obtained renal biopsy specimens and demonstrated ...