Furosemide and Creatinine Tubular Stress Test in Order to Measure Proximal Tubule Residual Function
Summary
This is a two phase study. The first part will take place at the National Institute of Cardiology in Mexico, the second phase will be made in collaboration with the University of California San Diego and University of Minnesota. This is a non blind experimental study, 72 patients with different stages of CKD from the outpatient unit of the institute will be included. Each patient will receive a furosemide stress test of 1 mg/kg in non diuretic users and 1.5 mg/kg in diuretic users, in addition of 5 grams of creatinine oral intake, as well as Iohexol 5ml IV to measure GFR. After the intervention, blood and urine samples will be drawn at baseline, 60 minutes, 180 minutes, and 240 min. Urine output will be maintained during the study by the intravenous administration of Hartman's solution 1 -2 ml/kg body weight every hour, in addition to the volume of urine output in the preceding hour plus oral water ingestion as tolerated. Blood and urine will be analized to measure creatinine (blood and urine), then samples will be processed for measurement of furosemide (HPLC-Uv vis), indoxyl sulphate, p-cresol, hippurate, and iohexol (mass spectometry). The aim of this stiudy is to asses the differences between GFR and proximal tubule function.
Timeline
- Start
- 2020-03-03
- Primary completion
- 2023-10-21
- Completion
- 2024-08-27
Publications
- Background Bullen AL, Fregoso A, Ascher SB, Shlipak MG, Ix JH, Rifkin DE. Markers of Kidney Tubule Dysfunction and Major Adverse Kidney Events. Nephron. 2023;147(12):713-716. doi: 10.1159/000531946. Epub 2023 Jul 31.
- Background Liu BC, Tang TT, Lv LL, Lan HY. Renal tubule injury: a driving force toward chronic kidney disease. Kidney Int. 2018 Mar;93(3):568-579. doi: 10.1016/j.kint.2017.09.033. Epub 2018 Jan 17.
- Background Armenta A, Madero M, Rodriguez-Iturbe B. Functional Reserve of the Kidney. Clin J Am Soc Nephrol. 2022 Mar;17(3):458-466. doi: 10.2215/CJN.11070821. Epub 2021 Nov 10.
- Background Lowenstein J, Grantham JJ. Residual renal function: a paradigm shift. Kidney Int. 2017 Mar;91(3):561-565. doi: 10.1016/j.kint.2016.09.052.
- Background Toth-Manikowski SM, Sirich TL, Meyer TW, Hostetter TH, Hwang S, Plummer NS, Hai X, Coresh J, Powe NR, Shafi T. Contribution of 'clinically negligible' residual kidney function to clearance of uremic solutes. Nephrol Dial Transplant. 2020 May 1;35(5):846-853. doi: 10.1093/ndt/gfz042.
- Background Mair RD, Lee S, Plummer NS, Sirich TL, Meyer TW. Impaired Tubular Secretion of Organic Solutes in Advanced Chronic Kidney Disease. J Am Soc Nephrol. 2021 Nov;32(11):2877-2884. doi: 10.1681/ASN.2021030336. Epub 2021 Aug 18.
- Background Koepsell H. Organic Cation Transporters in Health and Disease. Pharmacol Rev. 2020 Jan;72(1):253-319. doi: 10.1124/pr.118.015578.
- Background Emami Riedmaier A, Nies AT, Schaeffeler E, Schwab M. Organic anion transporters and their implications in pharmacotherapy. Pharmacol Rev. 2012 Jul;64(3):421-49. doi: 10.1124/pr.111.004614. Epub 2012 Mar 28.
- Background Rehberg PB. Studies on Kidney Function: The Rate of Filtration and Reabsorption in the Human Kidney. Biochem J. 1926;20(3):447-60. doi: 10.1042/bj0200447. No abstract available.
- Background Rodriguez-Iturbe B, Herrera J, Marin C, Manalich R. Tubular stress test detects subclinical reduction in renal functioning mass. Kidney Int. 2001 Mar;59(3):1094-102. doi: 10.1046/j.1523-1755.2001.0590031094.x.
- Background Shannon JA. THE RENAL EXCRETION OF CREATININE IN MAN. J Clin Invest. 1935 Jul;14(4):403-10. doi: 10.1172/JCI100691. No abstract available.
- Background Koyner JL, Davison DL, Brasha-Mitchell E, Chalikonda DM, Arthur JM, Shaw AD, Tumlin JA, Trevino SA, Bennett MR, Kimmel PL, Seneff MG, Chawla LS. Furosemide Stress Test and Biomarkers for the Prediction of AKI Severity. J Am Soc Nephrol. 2015 Aug;26(8):2023-31. doi: 10.1681/ASN.2014060535. Epub 2015 Feb 5.
- Background Rivero J, Rodriguez F, Soto V, Macedo E, Chawla LS, Mehta RL, Vaingankar S, Garimella PS, Garza C, Madero M. Furosemide stress test and interstitial fibrosis in kidney biopsies in chronic kidney disease. BMC Nephrol. 2020 Mar 6;21(1):87. doi: 10.1186/s12882-020-01721-z.
- Background Wu W, Bush KT, Nigam SK. Key Role for the Organic Anion Transporters, OAT1 and OAT3, in the in vivo Handling of Uremic Toxins and Solutes. Sci Rep. 2017 Jul 10;7(1):4939. doi: 10.1038/s41598-017-04949-2.
- Background Lim YJ, Sidor NA, Tonial NC, Che A, Urquhart BL. Uremic Toxins in the Progression of Chronic Kidney Disease and Cardiovascular Disease: Mechanisms and Therapeutic Targets. Toxins (Basel). 2021 Feb 13;13(2):142. doi: 10.3390/toxins13020142.
- Background Eloot S, Schepers E, Barreto DV, Barreto FC, Liabeuf S, Van Biesen W, Verbeke F, Glorieux G, Choukroun G, Massy Z, Vanholder R. Estimated glomerular filtration rate is a poor predictor of concentration for a broad range of uremic toxins. Clin J Am Soc Nephrol. 2011 Jun;6(6):1266-73. doi: 10.2215/CJN.09981110. Epub 2011 May 26.
- Background Tang J, Liu N, Zhuang S. Role of epidermal growth factor receptor in acute and chronic kidney injury. Kidney Int. 2013 May;83(5):804-10. doi: 10.1038/ki.2012.435. Epub 2013 Jan 16.
- Background Sauvant C, Hesse D, Holzinger H, Evans KK, Dantzler WH, Gekle M. Action of EGF and PGE2 on basolateral organic anion uptake in rabbit proximal renal tubules and hOAT1 expressed in human kidney epithelial cells. Am J Physiol Renal Physiol. 2004 Apr;286(4):F774-83. doi: 10.1152/ajprenal.00326.2003. Epub 2003 Nov 25.
- Background Caetano-Pinto P, Jamalpoor A, Ham J, Goumenou A, Mommersteeg M, Pijnenburg D, Ruijtenbeek R, Sanchez-Romero N, van Zelst B, Heil SG, Jansen J, Wilmer MJ, van Herpen CML, Masereeuw R. Cetuximab Prevents Methotrexate-Induced Cytotoxicity in Vitro through Epidermal Growth Factor Dependent Regulation of Renal Drug Transporters. Mol Pharm. 2017 Jun 5;14(6):2147-2157. doi: 10.1021/acs.molpharmaceut.7b00308. Epub 2017 May 24.
- Background Hropot M, Fowler N, Karlmark B, Giebisch G. Tubular action of diuretics: distal effects on electrolyte transport and acidification. Kidney Int. 1985 Sep;28(3):477-89. doi: 10.1038/ki.1985.154.
- Background Burki R, Mohebbi N, Bettoni C, Wang X, Serra AL, Wagner CA. Impaired expression of key molecules of ammoniagenesis underlies renal acidosis in a rat model of chronic kidney disease. Nephrol Dial Transplant. 2015 May;30(5):770-81. doi: 10.1093/ndt/gfu384. Epub 2014 Dec 18.
- Background Bergwik J, Kristiansson A, Allhorn M, Gram M, Akerstrom B. Structure, Functions, and Physiological Roles of the Lipocalin alpha1-Microglobulin (A1M). Front Physiol. 2021 Mar 3;12:645650. doi: 10.3389/fphys.2021.645650. eCollection 2021.
- Background Cheng CJ, Nizar JM, Dai DF, Huang CL. Transport activity regulates mitochondrial bioenergetics and biogenesis in renal tubules. FASEB J. 2024 May 31;38(10):e23703. doi: 10.1096/fj.202400358RR.
- Background Karagiannidis AG, Theodorakopoulou MP, Pella E, Sarafidis PA, Ortiz A. Uromodulin biology. Nephrol Dial Transplant. 2024 Jun 28;39(7):1073-1087. doi: 10.1093/ndt/gfae008.
- Background Horsch M, Beckers J, Fuchs H, Gailus-Durner V, Hrabe de Angelis M, Rathkolb B, Wolf E, Aigner B, Kemter E. Uromodulin retention in thick ascending limb of Henle's loop affects SCD1 in neighboring proximal tubule: renal transcriptome studies in mouse models of uromodulin-associated kidney disease. PLoS One. 2014 Nov 19;9(11):e113125. doi: 10.1371/journal.pone.0113125. eCollection 2014.
- Background Schmit DJ, Carroll LJ, Eckfeldt JH, Seegmiller JC. Verification of separate measurement procedures where analytical determinations influence the clinical interpretation of GFR: Iohexol quantitation by HPLC and LC-MS/MS. Clin Biochem. 2019 May;67:16-23. doi: 10.1016/j.clinbiochem.2019.03.007. Epub 2019 Mar 21.
- Background Seegmiller JC, Wolfe BJ, Albtoush N, Melena I, Gross SP, Vinovskis C, Ix JH, Bjornstad P. Tubular Secretion Markers, Glomerular Filtration Rate, Effective Renal Plasma Flow, and Filtration Fraction in Healthy Adolescents. Kidney Med. 2020 Aug 7;2(5):670-672. doi: 10.1016/j.xkme.2020.05.013. eCollection 2020 Sep-Oct. No abstract available.
- Madero M, Fernandez-Yepez AK, Resendiz-Albor AA, Rivera Chavez JA, Seegmiller JC, Rodriguez-Iturbe B. Estimation of Proximal Tubular Function by Stimulation of Organic Anion and Cation Transporters. J Am Soc Nephrol. 2025 Mar 24;36(9):1786-1797. doi: 10.1681/ASN.0000000686.
Drugs
| Evaluation | Drug | Modality | Dose | Route |
|---|---|---|---|---|
| Subject | Creatinine | Small molecule | 5 g | Oral |
| Subject | Furosemide | Other / unclassified | 1 mg/kg | Intravenous |
| Subject | Furosemide | Other / unclassified | 1.5 mg/kg | Intravenous |
| Subject | Iohexol | Diagnostic / imaging agent | 5 ml | Intravenous |