Intravenous Administration Of Angiotensin Research Articles

Angiotensin-(1–7) infusion in COVID-19 patients admitted to the ICU: a seamless phase 1–2 randomized clinical trial

BackgroundThe coronavirus-related disease (COVID-19) is mainly characterized by a respiratory involvement. The renin-angiotensin system (RAS) has a relevant role in the pathogenesis of COVID-19, as the virus enters host’s cells via the angiotensin-converting enzyme 2 (ACE2).MethodsThis investigator-initiated, seamless phase 1–2 randomized clinical trial was conceived to test the safety and efficacy of continuous short-term (up to 7 days) intravenous administration of Angiotensin-(1–7) in COVID-19 patients admitted to two intensive care units (ICU). In addition to standard of care, intravenous administration of Angiotensin-(1–7) was started at 5 mcg/Kg day and increased to 10 mcg/Kg day after 24 h (Phase 1; open label trial) or given at 10 mcg/Kg day and continued for a maximum of 7 days or until ICU discharge (Phase 2; double-blind randomized controlled trial). The rate of serious adverse events (SAEs) served as the primary outcome of the study for Phase 1, and the number of oxygen free days (OFDs) by day 28 for Phase 2.ResultsBetween August 2020 and July 2021, when the study was prematurely stopped due to low recruitment rate, 28 patients were included in Phase 1 and 79 patients in Phase 2. Of those, 78 were included in the intention to treat analysis, and the primary outcome was available for 77 patients. During Phase 1, one SAE (i.e., bradycardia) was considered possibly related to the infusion, justifying its discontinuation. In Phase 2, OFDs did not differ between groups (median 19 [0–21] vs. 14 [0–18] days; p = 0.15). When patients from both phases were analyzed in a pooled intention to treat approach (Phase 1–2 trial), OFDs were significantly higher in treated patients, when compared to controls (19 [0–21] vs. 14 [0–18] days; absolute difference −5 days, 95% CI [0–7] p = 0.04).ConclusionsThe main findings of our study indicate that continuous intravenous infusion of Angiotensin-(1–7) at 10 mcg/Kg day in COVID-19 patients admitted to the ICU with severe pneumonia is safe. In Phase II intention to treat analysis, there was no significant difference in OFD between groups.Trial Registration ClinicalTrials.gov Identifier: NCT04633772—Registro Brasileiro de Ensaios Clínicos, UTN number: U1111-1255-7167.

Hyperglycemic action of angiotensin II in freely moving rats.

Angiotensin II has been implicated in the regulation of liver glycogen phosphorylase. Although it has been suggested that angiotensin II can raise blood glucose levels during hemorrhage, experimental data have not been presented. In the present study, the effect of angiotensin II on blood glucose levels was studied in freely moving rats, divided in three experimental groups: 1) intravenous administration of angiotensin II (0.48, 1.9, or 4.8 nmol) caused a dose-dependence response; 2) intracerebroventricular administration of angiotensin II (1.9 or 4.8 nmol) did not cause any significant change in glycemia compared with saline-treated controls; 3) intravenous administration of [Sar1,Thr8]angiotensin II, an antagonist of angiotensin II (750 ng/100 g b. wt. as a bolus plus a continuous injection of 25 ng/100 g b. wt./min over 30 min), greatly attenuated (39.2% lower than controls; p < 0.01) the hyperglycemic response to hemorrhage (1.2 ml/100 g b.wt.). These data indicate an in vivo involvement of angiotensin II in blood glucose regulation.

In vivo metabolism of angiotensin I by neutral endopeptidase (EC 3.4.24.11) in spontaneously hypertensive rats.

We investigated the processing enzymes involved in the formation of circulating angiotensin-(1-7) after intravenous administration of angiotensin I to conscious spontaneously hypertensive and Wistar-Kyoto rats. Immunoreactive products, including angiotensin I, angiotensin II, and angiotensin-(1-7), were measured in arterial blood by three specific radioimmunoassays. Angiotensin I infusion (2 nmol) induced a rapid increase in immunoreactive angiotensin II and angiotensin-(1-7). Pretreatment with the angiotensin converting enzyme inhibitor enalaprilat (2 mg/kg) eliminated angiotensin II formation and augmented circulating levels of angiotensin I and angiotensin-(1-7) in spontaneously hypertensive and Wistar-Kyoto rats. The elevated levels of angiotensin-(1-7) in enalaprilat-treated rats were blocked by concurrent treatment with the neutral endopeptidase (EC 3.4.24.11) inhibitor SCH 39,370 (15 mg/kg) in both strains. Administration of SCH 39,370 alone decreased angiotensin-(1-7) levels in spontaneously hypertensive rats, whereas angiotensin II levels increased in both strains (p less than 0.01). Comparisons of the metabolism of angiotensin I in the two rat strains showed increased formation of angiotensin-(1-7) in spontaneously hypertensive rats not given any of the enzyme inhibitors. In addition, levels of angiotensin I were higher after administration of SCH 39,370 in hypertensive rats. These novel findings reveal that neutral endopeptidase EC 3.4.24.11 participates in the conversion of angiotensin I to angiotensin-(1-7) and in the metabolism of angiotensin II in the circulation of both spontaneously hypertensive and Wistar-Kyoto rats. Our results suggest that neutral endopeptidase EC 3.4.24.11 is a major enzymatic constituent of the circulating renin-angiotensin system.

Simultaneous measurement of two major prostacyclin metabolites in urine

We describe a combined HPLC-RIA technique to measure both major metabolites of prostacyclin (PGI2): 6-keto PGF1 alpha and 2,3-dinor-6 keto PGF1 alpha. The measurement of the former, which originates from renal blood vessels, and the latter, from systemic vessels and the liver, may provide a better overall evaluation of production than measurement of one metabolite. An aliquot of acidified urine with added 3H-labeled metabolites is adsorbed and then eluted from a C18 Bond-Elut column. The sample is then passed through an HPLC system by use of an isocratic solvent combination that separates the two metabolites from known prostaglandins. The purified metabolites are then quantified by RIA. Using a logit-log10 transform, one can measure between 12 and 250 pg of either metabolite, with high accuracy and precision (CVs of 12% for a low concentration and 7% for a high concentration). Reference values for apparently healthy subjects were, respectively, 107 (SD 45) and 171 (SD 69) ng/g creatinine for 6-keto PGF1 alpha and the dinor metabolite in men (n = 18) and 45 (SD 22) and 141 (SD 28) ng/g creatinine, respectively, in women (n = 15). Indomethacin in standard doses reduced both metabolite values by 50%. Intravenous administration of angiotensin II (5 ng/kg of body wt per minute) did not alter excretion rates, but equipressor doses of norepinephrine (0.1 microgram/kg per minute) increased the production of both metabolites (6-keto greater than dinor).

The effect of prolonged infusion and withdrawal of angiotensin II in the spontaneously hypertensive rat.

In spontaneously hypertensive rats (SHR) and their normotensive Wistar-Kyoto controls (WKY), prolonged intravenous administration of angiotensin II (AII, 0.2 microgram X kg-1 X min-1 for 3h) resulted in similar increases in arterial blood pressure. Heart rate decreased in WKY and increased in SHR. At the end of the infusion, blood pressure dropped substantially in SHR, but not in WKY: at 5 h after AII withdrawal, blood pressure in SHR had fallen from a control value of 172 +/- 3.3 to 146 +/- 3.9 mmHg (p less than 0.01), whereas pressure in WKY had fallen from 116 +/- 3.0 to 107 +/- 4.2 mmHg (statistically non significant). Thus, pressure at 5 h after AII withdrawal was still substantially higher (p less than 0.01) in the SHR than in the WKY. The results demonstrate that the fall in blood pressure following withdrawal of a prolonged infusion of AII in SHR is much less than that reported to occur following withdrawal of a prolonged infusion of vasopressin (AVP) in SHR.

Effects of nicardipine on aldosterone release and pressor mechanisms.

This study evaluated the effects of nicardipine, following intravenous infusion and oral administration, on the pressor and aldosterone responses to infused angiotensin II. Six healthy, normotensive male subjects were studied. Following administration of nicardipine, no significant change in blood pressure was seen. Nicardipine attenuated the pressor response produced by intravenous administration of angiotensin. Nicardipine did not inhibit the aldosterone response to angiotensin.

Central actions of angiotensin II oppose baroreceptor-induced sympathoinhibition.

Angiotensin II causes increased arterial pressure which may be mediated, in part, by effects on central sympathetic neurons or by interference with central or peripheral components of the baroreceptor reflex. This investigation was undertaken to determine actions of angiotensin II on sympathetic splanchnic efferent and carotid sinus afferent activity in chloralose-anesthetized cats. Neural responses during increases in arterial pressure caused by intracarotid or intravenous administration of angiotensin II were compared with responses to equivalent increases in arterial pressure induced by intravenously injected dextran or phenylephrine. Intracarotid injections of angiotensin II caused variable splanchnic sympathetic responses consisting of increased, decreased, or unchanged activity. In contrast, intravenous infusions of dextran or phenylephrine consistently inhibited sympathetic activity. Carotid sinus afferent activity was increased similarly by intracarotid angiotensin II and intravenous dextran or phenylephrine. Sympathetic and baroreceptor afferent responses to intravenously injected angiotensin II were not significantly different from responses to dextran or phenylephrine. These data demonstrate that angiotensin II can act centrally to excite sympathetic outflow or to interfere with inhibitory influences of arterial baroreceptors.

Vasoconstrictor effect of angiotensin on pial arteries.

The effect of topical application of angiotensin on pial arterioles was examined in anesthetized cats equipped with a cranial window for the direct observation of the pial microcirculation of the parietal cortex. Angiotensin in a dose of 0.01 to 1 microgram/ml constricted pial arterioles and arteries strongly. The response of the smaller vessels was greater than that of the larger ones. Intravenous administration of angiotensin in a dose of 0.04--3.8 microgram/min raised arterial blood pressure and constricted the larger pial arteries. While the infusion of angiotensin was continued at the same dose, the blood pressure was then reduced to the control level via bleeding into a reservoir. This abolished the vasoconstriction of the larger pial arteries, showing that this effect was due to autoregulatory adjustments to the rise in blood pressure and not due to a direct effect of angiotensin. We conclude that, despite the strong constrictor effect of angiotensin on pial arteries, intravenous angiotensin can be used to study the effects of arterial hypertension on the cerebral circulation.

Effects of acutely induced hypertension in cats on pial arteriolar caliber, local cerebral blood flow, and the blood-brain barrier.

Acute hypertension was induced in 19 anesthetized cats by the intravenous administration of angiotensin. The caliber of pial arteries was measured by a television image-splitting technique and local cerebral blood flow by the hydrogen clearance technique. As the blood pressure was increased, pail arterioles constricted and cerebral blood flow remained relatively constant, showing that autoregulation of cerebral blood flow was intact. At mean arterial pressures of more than 170 mm Hg arteriolar dilation appeared. In smaller arterioles (initial diameter less than 100 mum) a segmental dilation (the "sausage'string" phenomenon) frequently preceded uniform dilation. This arteriolar dilation was associated with a marked increase in local cerebral blood flow indicating that the upper level of autoregulation had been breached. In no cat was vasospasm or a decrease in blood flow observed during induced hypertension. Hypertension also caused dysfunction of the bloodbrain barrier since, in 17 out of 19 of the cats examined, there was extravasation of protein-bound Evans blue into brain tissue. In only one of the 19 cats subjected to neuropathological analysis was ischemic brain damage identified and this was restricted to minimal ischemic cell change. The results indicate that severe, induced hypertension in cats produces cerebral arteriolar dilation, an increase of cerebral blood flow, and dysfunction of the blood-brain barrier. These observations may be of importance in understanding the pathogenesis of hypertensive encephalopathy.