Early alteration in glomerular reserve in humans at genetic risk of essential hypertension - Mechanisms and consequences

Essential hypertension has a familial predisposition, but the phenotype of elevated blood pressure has delayed penetrance. Because the kidney is a crucial determinant of blood pressure homeostasis, we studied early glomerular alterations in still-normotensive young subjects at genetic risk of hypertension. Thirty-nine normotensive adults (mean age 29 to 31 years), stratified by genetic risk (parental family history [FH]) of hypertension (26 with positive FH [FH+], 13 with negative FH [FH-]), underwent intravenous infusion of mixed amino acids. Before and during amino acid administration, we measured glomerular filtration rate (GFR), putative second messengers of amino acids (nitric oxide [NO] metabolites and cGMP), serum insulin and amino acid concentrations, and the FELi+ as an index of renal proximal tubular reabsorption. The FH+ group had a blunted GFR rise in response to amino acids (2.43 +/- 8.16% versus 31.0+/-13.4% rise, P=0.0126). The amino acid-induced change in GFR correlated (r=0.786, P<0.01) with the change in urinary NO metabolite excretion; a diminished rise in urinary NO metabolite excretion in the FH+ group (P=0.0105) suggested a biochemical mechanism for the different GFR responses between FH groups: a relative inability to convert arginine to NO. The FH+ group had a far lower initial cGMP excretion at baseline (261+/-21.1 versus 579+/-84.9 nmol . h(-1)/1.73 m(2), P=0.001), although cGMP did not change during the amino acid infusion (P=0.703). FH status, baseline GFR, and baseline serum insulin jointly predicted GFR response to amino acids (P=0.0013), accounting for 45% of the variance in GFR response. Decline in FELi+, an inverse index of proximal tubular reabsorption, paralleled increase in GFR (r=-0.506, P=0.01), suggesting differences in proximal tubular reabsorption during amino acids between the FH groups. GFR response to amino acid infusion was blunted in the FH+ group despite significantly higher serum concentrations of 6 amino acids (arginine, isoleucine, leucine, methionine, phenylalanine, and valine) in the FH+ group, suggesting a novel form of insulin resistance (to the amino acid-translocating action of insulin) in FH + subjects. We conclude that blunted glomerular filtration reserve in response to amino acids is an early-penetrance phenotype seen even in still-normotensive subjects at genetic risk of hypertension and is linked to impaired formation of NO in the kidney. Corresponding changes in GFR and fractional excretion of Li+ suggest that altered proximal tubular reabsorption after amino acids is an early pathophysiologic mechanism. Resistance to the amino acid-translocating actions of insulin may play a role in the biological response to amino acids in this setting. This glomerular reserve phenotype may be useful in genetic studies of renal traits preceding or predisposing to hypertension.