Na؉ reabsorption by the epithelial Na ؉ channel (ENaC) in cortical collecting duct provides the final renal adjustment to Na A n increase in Na ϩ and water retention is required for the development of most forms of hypertension as was proposed by Guyton years ago (1) and to this day has never really been refuted. In instances in which the mechanism for the hypertension is known, in which an identified gene mutation defines it, generally speaking an increase in the function of the epithelial Na ϩ channel (ENaC) leads to the Na ϩ retention and elevation in BP (2). The bigger question and the issue addressed in the current review is the extent to which ENaC participates in the development of common forms of hypertension. A strong case can be made for the fact that ENaC is pivotally positioned, both anatomically and physiologically, to convey a dominant influence on the prevalence of hypertension. Studies of hypertension in relation to ENaC and its major regulator, aldosterone, are reviewed here, and a general mechanism for development of hypertension is formulated. Finally, a clinical trial of the effectiveness of ENaC inhibition to lower BP in patients with hypertension is described.
Common Molecular Variations in ENaC and Risk for HypertensionThe discovery of mutations in -and ␥-subunits of ENaC to explain Liddle syndrome (3,4), a severe form of low-renin hypertension (5), was soon followed by a search for common genetic variants in ENaC subunits that affect susceptibility in less rare forms of hypertension. Of course variants were identified, and they were almost universally more common in black individuals, which fit nicely with the higher prevalence of low-renin hypertension in black individuals. After a number of years of study by several investigative groups, however, it remains unestablished that a given variant influences the risk for hypertension.The first molecular variant to show an association with hypertension was T594M in the C-terminus of -ENaC (Figure 1) in a study of black individuals who lived in London (6) (the variant is rare in white individuals). Frequencies of the variant were found to be 8.3% in hypertensive individuals and 2.4% in normotensive individuals. In addition, plasma renin activity was lower in carriers of T594M. Subsequent studies by others have for the most part failed to replicate the same relationship to hypertension (7,8). In another study, seven molecular variants, all in -ENaC, with overall allele frequencies of 44% in black individuals and 1% in white individuals, showed no association with hypertension and showed no effect on function using two different in vitro techniques (7). In our own laboratory, we found a G442V variant in the extracellular loop (Figure 1) in -ENaC (again occurring almost exclusively in black individuals) significantly associated with an index of ENaC activity, the urinary aldosterone/K ϩ ratio, in normotensive young people, but it did not associate with hypertension in a study of adults (8). We also found that the A663T variant inPublished onli...