Open Access Peer-Reviewed
Original Article

Urinary cytokine profiles according to the site of blockade of the renin-angiotensin system in nephrectomized rats

Perfil de citocinas urinárias de acordo com o local de bloqueio do sistema renina angiotensina em ratos nefrectomizados

Nilo César do Vale Baracho; Kátia Daniela da Silveira; Natália Pessoa Rocha; Thiago Macedo Cordeiro; Victor Feracin; Regina Maria Pereira; Marconi Augusto Aguiar dos Reis; Mauro Martins Teixeira; Ana Cristina Simões e Silva

DOI: 10.5935/0101-2800.20170028


INTRODUCTION: It is still unknown how the pharmacological inhibition of the Renin Angiotensin System (RAS) impacts the levels of inflammation and fibrosis biomarkers.
OBJECTIVE: This study sought to evaluate the effect of enalapril, candesartan and aliskiren on urinary levels of cytokines in a model of chronic kidney disease (CKD).
METHODS: Male Wistar rats were submitted to surgical removal of ¾ of renal parenchyma to induce CKD (¾ nephrectomy), or subjected to sham surgery (control). Animals were then randomized into five groups: Sham surgery receiving vehicle; ¾ Nephrectomy receiving vehicle; ¾ Nephrectomy receiving enalapril (10 mg/kg); ¾ Nephrectomy receiving candesartan (10 mg/kg) and ¾ Nephrectomy receiving aliskiren (10 mg/kg). Urine output, water intake, mean arterial pressure (MAP) and urinary concentrations of creatinine, urea, albuminuria, Na+, K+, interleukin (IL) -1ß, IL-6, IL-10 and transforming growth factor beta (TGF-ß) were measured.
RESULTS: Nephrectomy significantly impaired renal function, increased MAP and altered the levels of all evaluated cytokines in urine. Enalapril, candesartan and aliskiren improved renal function and decreased MAP and IL-6 when compared to vehicle-treated nephrectomized group. Candesartan and aliskiren decreased IL-1ß, while only candesartan reduced TGF-ß and only aliskiren increased IL-10.
CONCLUSION: Enalapril, candesartan and aliskiren presented similar effects on improving renal function and reducing MAP and urinary levels of IL-6 in rats with CKD. On the other hand, cytokine profile differed according to the treatment, suggesting that differential mechanisms were triggered in response to the site of RAS blockade.

angiotensins; angiotensin-converting enzyme inhibitors; angiotensin receptor antagonists; kidney failure, chronic; nephrectomy.


INTRODUÇÃO: Ainda não se sabe como a inibição farmacológica do Sistema Renina Angiotensina (SRA) afeta os níveis de biomarcadores de inflamação e fibrose.
OBJETIVO: Este estudo pretendeu avaliar o efeito de enalapril, candesartan e alisquireno sobre os níveis urinários de citocinas em um modelo de doença renal crônica (DRC).
MÉTODOS: Ratos Wistar machos foram submetidos à remoção cirúrgica de ¾ do parênquima renal para induzir DRC (nefrectomia), ou submetidos à cirurgia fictícia (controle). Animais foram então randomizados em cinco grupos: Cirurgia fictícia recebendo veículo; Nefrectomia recebendo veículo; Nefrectomia recebendo enalapril (10 mg/kg); Nefrectomia recebendo candesartan (10 mg/kg) e Nefrectomia recebendo alisquireno (10 mg/kg). Débito urinário, ingesta hídrica, pressão arterial media (PAM) e concentrações urinárias de creatinina, ureia, albumina, Na+, K+, interleucina (IL) -1ß, IL-6, IL-10 e fator de transformação e crescimento beta (TGF-ß) foram medidas.
RESULTADOS: A nefrectomia comprometeu significativamente a função renal, aumentou a PAM e alterou os níveis de todas as citocinas avaliadas na urina. Enalapril, candesartan e alisquireno melhoraram a função renal e diminuíram a PAM e a IL-6 quando comparado aos grupo de animais nefrectomizados tratados com veículo. Candesartan e alisquireno reduziram IL-1ß, enquanto somente candesartan diminuiu o TGF-ß e somente alisquireno aumentou a IL-10.
CONCLUSÃO: Enalapril, candesartan e alisquireno apresentaram efeitos similares em relação à melhora da função renal e redução da PAM e dos níveis urinários de IL-6 em ratos com DRC. Por outro lado, o perfil de citocinas diferiu de acordo com o tratamento, sugerindo que diferentes mecanismos sejam desencadeados em resposta ao local de bloqueio do SRA.

angiotensinas; antagonistas de receptores de angiotensina; falência renal crônica; inibidores da enzima conversora de angiotensina; nefrectomia.


Citation: Baracho NCV, Silveira KD, Rocha NP, Cordeiro TM, Feracin V, Pereira RM, et al. Urinary cytokine profiles according to the site of blockade of the renin-angiotensin system in nephrectomized rats. J Bras Nefrol 39(02):108. doi:10.5935/0101-2800.20170028
Financial support: This study was partially supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq, Brazil - grants number 470472/2014-6 and 460334/2014-0), Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG, Brazil - grant number CDS - PPM-00555-15), and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).
Received: October 05 2016; Accepted: February 08 2017


The renoprotective effects of the Renin Angiotensin System (RAS) inhibition in chronic kidney disease (CKD) seems to extend far beyond the control of arterial hypertension.1-3 Angiotensin converting enzyme inhibitors (ACEi) and angiotensin type 1 (AT1) receptor antagonists (ARA) slow the progression of CKD not only by reducing blood pressure, but also because of their antioxidant, anti-proliferative, anti-inflammatory and anti-fibrogenic effects.1-3 More recently, renin inhibitors started being used as a novel modality of RAS blockade.4 Aliskiren, the prototype of renin inhibitors, also presented renoprotective effects in non-diabetic CKD.5

Inflammation is known to play an important role in CKD pathogenesis. The levels of inflammation-related molecules, including like C-reactive protein, chemokines and cytokines are increased in patients with CKD.6-8 CKD patients exhibit a pro-inflammatory profile since initial stages, which, in turn, might contribute to disease progression.9-11 In addition to inflammation, the RAS plays a pivotal role in the pathophysiology of CKD.3,12,13

An exacerbated stimulation of the RAS promotes intrarenal production of Angiotensin (Ang) II that binds to AT1 receptor producing glomerular and systemic hypertension, endothelial injury, and proteinúria.12,14,15 Clinical and experimental studies have also drawn attention to the interactions between Ang II and cytokines, chemokines and growth factors, contributing to the progression of CKD.3,12,16,17 Ang II recruits inflammatory cells, induced the release of cytokines and directly stimulates intracellular signaling mechanisms related to kidney inflammation and fibrosis.3,12,18,19

Previous studies have shown that interleukin (IL)-1ß and IL-6 are major inflammatory mediators in renal diseases,6,8,11 whereas transforming growth factor beta (TGF-ß) is an important mediator of kidney tissue fibrosis.18-20 In addition, the interaction of Ang II with these molecules has been previously reported in experimental models and in human renal diseases.12,13,16,18,19 In addition, some studies have shown the anti-inflammatory actions of IL-1021-23 in renal diseases. Herein, we aimed to evaluate the urinary cytokine profile in response to three different sites of pharmacological blockade of the RAS in an experimental model of CKD stage III.



This study included 60 adult (aged 60 - 90 days), male Wistar rats, weighing 200-250g, Animals were maintained under temperature-controlled conditions with an artificial 12-h light/dark cycle and receiving standard chow and water ad libitum. Rats were bred at the animal facility of the Faculty of Medicine of Itajubá (MG, Brazil). The study was approved by the Ethics Committee on Animal Welfare of Federal University of Minas Gerais (UFMG, Brazil), according to the protocol CETEA 03/09.

Experimental design and surgical procedures

For surgical procedures, animals received intraperitoneal injection of ketamine (50 mg/kg) and xylazine (25 mg/kg). In order to induce moderate CKD, animals underwent surgical removal of ¾ of the renal parenchyma, according to the guidelines of Ormrod & Miller.24 As a control group, animals underwent sham surgery.

Sham surgery - control group

Anesthesia, shaving, asepsis and left flank incision were performed to expose the left kidney, followed by dissection of adhering fat and renal capsule, preserving the adrenal gland. After that, a very small slice of renal cortical tissue was removed. Seven days later, right kidney was exposed and manipulated.

Moderate CKD - ¾ nephrectomy

Anesthesia, shaving, asepsis and flank incision were performed with exposure of the left kidney followed by dissection of adherent fat and renal capsule, preserving the adrenal glands. Similarly to the previous group, the left kidney was exposed to remove upper and lower poles with surgical excision of cortical tissue from the outer side portion of the left kidney. After seven days, right renal pedicle was ligated and the right kidney removed.

After recovery from anesthesia, animals were allocated into five experimental groups (n = 10 per group), housed in metabolic cages (Tecniplast, USA), with free access to water and standard rat chow. After 72 hours of adaptation period, animals were randomized to daily receive the following treatments per gavage for 14 days:

  • Control group- sham surgery: distilled water (vehicle);
  • Nephrectomy ¾: distilled water (vehicle);
  • Nephrectomy ¾: enalapril maleate 10 mg/kg;
  • Nephrectomy ¾: candesartan 10 mg/kg;
  • Nephrectomy ¾: aliskiren 10 mg/kg.

All animals were subjected to mean blood pressure measurement by tail plethysmography once a week. Urine output, water and food intake were daily measured. At the end of the experimental period (14th day), blood samples were withdrawn by cardiac puncture, under ketamine and xylazine anesthesia (50 mg/kg and 25 mg/kg, respectively), and centrifuged at 2,500 rpm for 15 min at 4°C. Samples of serum and 24-hour urine were collected at the last day of the experiment and they were stored at - 20°C to measure creatinine, urea, Na+, K+, IL-1ß, IL-6, IL-10 and TGF-ß. At the end of experimental protocol (14th day), the animals were euthanized and the kidneys were removed and cut into 2 mm slices, which were fixed for 24 hours in 10% buffered formalin.

Treatments and doses

The doses and RAS blockers tested have been quite variable in previous studies. Our protocol was based on previous studies that evaluated daily administration of oral treatments in adult rats. Thus, the ACEi of this study was enalapril maleate at a dose of 10 mg/Kg/day based on previous experimental studies with rats.25,26

The ARA was candesartan cilexetil at a dose of 10 mg/kg/day based on the study of Lin and co-workers reporting anti-hypertensive and anti-inflammatory effects with daily oral doses of 10 to 15 mg/Kg/day in Dahl salt-hypertensive rats.27 The reported doses for Aliskiren in experimental studies have varied from 5 mg/Kg/day28 to 100 mg/Kg/day.29 For this reason, we performed a preliminary test with the doses of 10 (n = 5) and 100 mg/Kg/day (n = 5) and both doses elicited similar effects on blood pressure, renal function parameters and urinary cytokine measurements (data not shown). Therefore, we adopted the dose of 10 mg/kg/day for Aliskiren.

General measurements and renal function parameters

To evaluate renal function parameters, serum and urinary creatinine were determined by modified Jaffé colorimetric method (Labtest, Minas Gerais, Brazil). Serum urea was determined by the enzymatic method (Labtest, Minas Gerais, Brazil). Serum and urinary sodium and potassium concentrations were measured by flame photometry (CELM, Minas Gerais, Brazil) and microalbuminuria quantification was performed by turbidimetry (Gold Diagnostic analyzes, Minas Gerais, Brazil).

Urinary cytokines measurements

Urinary levels of IL-1ß, IL-6, IL-10 and TGF-ß1 were measured at day 14 by enzyme-linked immunosorbent assay (ELISA) kits from R&D Systems (Minneapolis, MN, USA), following the manufacturer''s instructions. All samples were analyzed in duplicate. Urinary concentrations of cytokines were expressed as values relative to urinary creatinine measured simultaneously in the same urine sample (pg/mg Cr). The limits of detection for each cytokine were: 0.1 mg/ml for IL-1ß, 0.039 pg/ml for IL-6 and 6 pg/ml for IL-10 and TGF-ß1. Measurements of IL-1ß, IL-6, IL-10 and TGF-ß1 were performed in a single assay to avoid inter-assay variations. The intra-assay variation was less than 3%.

Kidney histopathology

After fixation, the sections were embedded in paraffin, sliced into 5 micra slides and stained with Hematoxylin & Eosin (HE). Afterwards, the histological slides were examined in a blinded manner to experimental protocol under an optical microscope (Nikon Eclipse, Japan). Images of illustrative fields were obtained.

Statistical analysis

Results were expressed as mean ± standard error of mean (SEM). Analysis of variance (ANOVA) was used to compare means between multiple groups, followed by Student-Newman-Keuls post hoc test. The level of significance was set at p < 0.05.


General measurements

Urine output of the animals is shown in Figure 1A. Nephrectomy group that received vehicle showed a significant increase in urine output from day 1 until the end of the experiment when compared with control group (p < 0.05) and with treated animals (p < 0.05). On the other hand, nephrectomized rats treated with RAS blockers (enalapril, candesartan or aliskiren) were able to maintain urine output similar to control group. There was no significant difference in urine output between treated groups.

Water intake of the animals is shown in Figure 1B. Nephrectomized and vehicle-administered animals significantly increased water intake in comparison with control group (p < 0.05) and with treated animals (p < 0.05). As observed for urine output, all treatments (enalapril, candesartan or aliskiren) similarly restored water intake to values comparable to control group. The change in water intake occurred from day 2 until the end of the experiment.

Renal function parameters

Renal function parameters are displayed in table 1. All biochemical parameters of renal function were seriously compromised in the group of nephrectomized rats receiving vehicle when compared with control group (sham surgery) (p < 0.05 for all comparisons). On the other hand, the treatments with enalapril (10 mg/kg), candesartan (10 mg/kg) and aliskiren (10 mg/kg) produced significant improvements in all renal function parameters in comparison to nephrectomized animals receiving vehicle (p < 0.05). In addition, all treatments similarly restored renal function parameters to values detected in control group (Table 1).

Table 1. Renal function parameters of rats submitted to sham surgery (control group) or ¾ nephrectomy receiving different treatments (vehicle, enalapril, candesartan or aliskiren)
Parameters Sham surgery Vehicle Enalapril 10 mg/kg Candesartan 10 mg/kg Aliskiren 10 mg/kg
Serum Na+ (mEq/l) 141.3 ± 2.3 157.0 ± 2.1# 141.0 ± 2.3* 143.8 ± 3.0* 145.3 ± 3.8*
Serum K+ (mEq/l) 4.3 ± 0.2 5.8 ± 0.3# 4.5 ± 0.5* 4.4 ± 0.4* 4.8 ± 0.6*
Urinary Na+ (mEq/l) 286.8 ± 28.2 185.3 ± 20.2# 268.3 ± 21.2* 274.3 ± 18.2* 265.3 ± 22.8*
Urinary K+ (mEq/l) 212.4 ± 32.3 173.5 ± 12.1# 210.0 ± 17.3* 219.2 ± 17.1* 208.2 ± 12.3*
Serum urea (mg/dL) 33.4 ± 3.5 162.3 ± 7.5# 40.3 ± 7.8* 38.3 ± 6.5* 40.8 ± 7.7*
Serum creatinine serum (mg/dL) 1.1 ± 0.2 5.3 ± 1.0# 1.5 ± 0.5* 1.4 ± 0.6* 1.8 ± 1.0*
Creatinine clearance (mL/min) 0.42 ± 0.04 0.16 ± 0.02# 0.38 ± 0.03* 0.37 ± 0.06* 0.36 ± 0.08*
Microalbuminuria (mg/day) 0.42 ± 0.4 52.3 ± 4.1# 1.0 ± 0.7* 0.8 ± 0.5* 1.0 ± 0.9*

Mean arterial pressure (MAP)

As expected, nephrectomized animals receiving vehicle had significantly higher MAP than control group (p < 0.05, Table 2). In contrast, all treatments (enalapril, candesartan and aliskiren) similarly reduced MAP (p < 0.05, Table 2) to levels comparable to control animals (p > 0.05).

Table 2. Mean blood pressure of rats submitted to sham surgery (control group) or ¾ nephrectomy receiving different treatments (vehicle, enalapril, candesartan or aliskiren).
Mean Blood Pressure (mmHg)  
Groups Day 14
Control (sham surgery) 108 ± 6
Vehicle (¾ nephrectomized + water) 161 ± 5#
Enalapril 10 mg/kg (¾ nephrectomized) 102 ± 8*
Candesartan 10 mg/kg (¾ nephrectomized) 105 ± 4*
Aliskiren 10 mg/kg (¾ nephrectomized) 122 ± 6*

Mean blood pressure of animals in all experimental groups was measured by tail plethysmography once a week. Results are presented by mean ± SEM of ten mice per group.

* p < 0.05: for comparisons with vehicle-administered group.

# p < 0.05: for the comparison between vehicle and control group (sham surgery).

Urinary levels of cytokines (IL-1ß, IL-6, TGF-ß, and IL-10)

As shown in Figure 2A-D, urinary levels of IL-1ß, IL-6, TGF-ß, and IL-10 significantly changed after ¾ nephrectomy in comparison with sham-surgery (control group).

Treatments with aliskiren and candersartan significantly reduced urinary levels of IL-1ß when compared to nephrectomized group receiving vehicle (85.5 ± 67.8 pg/mg cr vs. 1.3 ± 1.1 pg/mg cr following aliskiren treatment and undetectable levels after candesartan administration, Figure 2A). On the other hand, enalapril was not able to reduce urinary levels of IL-1ß.

Figure 2B showed that all treatments significantly reduced urinary levels of IL-6 (candesartan: 0.30 ± 0.13 pg/mg cr, aliskiren: 1.37 ± 0.53 pg/mg cr and enalapril 2.50 ± 1.25 pg/mg cr) when compared with vehicle administration (8.60 ± 4 .99 pg/mg cr, p < 0.05 for all comparisons), reaching values comparable to control group (0.48 ± 0.18 pg/mg cr).

Only candesartan treatment was able to significantly reduce the urinary levels of TGF-ß in comparison with vehicle-administered animals (1.17 ± 0.35 vs. 3.42 ± 1.09 pg/mg cr, p < 0.05, Figure 2C). In addition, whereas candesartan significantly reduced urinary levels of IL-10, aliskiren increased about four times in comparison with vehicle-administered animals (99.50 ± 36.14 pg/mg cr vs. 22.50 ± 21.50 pg/mg cr, p < 0.05, Figure 2D). Enalapril did not change urinary levels of IL-10 (11.80 ± 10.52 pg/mg cr) when compared to nephrectomized animals receiving vehicle (Figure 2D).

Table 3 displays all values of the measurements of urinary cytokines.

Table 3. Urinary levels of cytokines (pg/mg creatinine) of rats submitted to sham surgery (control group) or ¾ nephrectomy receiving different treatments (vehicle, enalapril, candesartan or aliskiren)
Cytokines (pg/mg cr) Sham surgery Vehicle Enalapril 10 mg/kg Candesartan 10 mg/kg Aliskiren 10 mg/kg
IL-1ß N.D. 85.50 ± 67.80# 27.33 ± 23.45 N.D* 1.30 ± 1.10*
IL-6 0.48 ± 0.18 8.60 ± 4.99# 2.50 ± 1.25* 0.30 ± 0.13* 1.37 ± 0.53*
TGF- ß 1.34 ± 0.47 3.42 ± 1.09# 2.48 ± 0.96 1.17 ± 0.35* 2.75 ± 0.83
IL-10 N.D. 22.50 ± 21.50# 11.80 ± 10.52 N.D. 99.50 ± 36.14*

N. D. = non-detectable levels

* p < 0.05: for comparisons with vehicle-administered group.

# p < 0.05: for the comparison between vehicle and control group (sham surgery).

Renal histopathology

Figure 3 shows representative slices of kidney tissue (400 x magnification) stained by HE from sham-operated rats receiving vehicle (control group, panel A), ¾ nephrectomized rats treated with vehicle (panel B), ¾ nephrectomized rats treated with enalapril (panel C), ¾ nephrectomized rats treated with candesartan (panel D) and ¾ nephrectomized rats treated with aliskiren (panel E). The control group showed normal renal histology (A).

In sharp contrast, ¾ nephrectomized rats receiving vehicle exhibited intense interstitial inflammatory infiltrate, glomerular disruption and abnormal tubular hypotrophy or dilatation with hyaline material in tubular lumen (panel B). Nephrectomized rats treated with enalapril (C) or candesartan (D) or aliskiren (E) presented less severe renal tissue alterations than nephrectomized rats receiving vehicle.

All treatments reduced glomerular and tubular damage in comparison with vehicle administration, showing a renoprotective effect. When compared to sham-operated rats, ¾ nephrectomized rats treated with RAS blockers had an augmentation of mesangial cellularity and of interstitial inflammation, discrete glomerular hypertrophy and mild tubular hypotrophy.


Our data showed that ACE inhibition, AT1 receptor antagonism and renin inhibition were similarly effective in reversing biochemical changes, reducing blood pressure, proteinuria and renal tissue damage produced by ¾ nephrectomy. On the other hand, the treatments with enalapril, candesartan and aliskiren changed urinary cytokines in a different way. In comparison with vehicle administration, AT1 receptor antagonism with candesartan significantly reduced urinary levels of all cytokines (IL-1ß, IL-6, TGF-ß and IL-10), whereas ACE inhibition with enalapril only decreased IL-6 levels. In contrast, renin inhibition with aliskiren was the only treatment that increased urinary levels of the anti-inflammatory cytokine IL-10.

The ¾ nephrectomy produced significant changes in renal function parameters, including urine output, plasma and urinary concentration of electrolytes, plasma levels of nitrogen waste products, creatinine clearance and urinary protein excretion. Polyuria and polydipsia can be attributed to alterations in mechanisms of urine concentration, related to the inability of vasopressin to stimulate reabsorption of water in the collecting ducts of these animals.30,31 The detection of lower urinary concentrations of sodium and potassium was also related to the reduced capacity of urine concentration.

On the other hand, Chamberlain & Shirley32 obtained different results in relation to sodium and potassium in rats submitted to unilateral and subtotal nephrectomy. The authors detected that overall sodium and potassium excretion changed little in unilateral nephrectomized rats, while in animals submitted to 5/6 nephrectomy, a small reduction in sodium and potassium excretion was observed only during the first week after surgery32.

These differences may be attributed at least in part to the use of different rat strains, since we used Wistar rats and the study of Chamberlain & Shirley32 evaluated Sprague-Dawley animals. In addition, Chamberlain & Shirley32 did not study renal function parameters following ¾ nephrectomy as in our study. It should be also mentioned that rats subjected to subtotal nephrectomy have elevated plasma levels of vasopressin30 and decreased gene expression of aquaporins 1, 2 and 3.31

In our study, we observed that all tested treatments reversed polyuria, polydipsia and changes in sodium and potassium concentrations produced by ¾ nephrectomy. It was not possible to determine the mechanisms by which RAS blockers normalized these parameters. However, Ang II is known to increase vasopressin secretion and dipsogenic effects.33 Thus, the reduction of Ang II synthesis in response to enalapril or aliskiren and the antagonism of AT1 receptors due to candesartan might reduce the release of vasopressin and water intake with consequent normalization of the volume and concentration of the urine.

All treatments also reduced serum creatinine levels, blood pressure and urinary protein excretion in ¾ nephrectomized animals. The improvement of renal function, blood pressure control and reduction of proteinuria in response to ACE inhibitors and AT1 blockers have been widely reported in experimental and clinical studies.1-3,12-14 However, our study is the first that evaluated the effects of aliskiren in rats subjected to ¾ nephrectomy.

Clinical studies have shown that aliskiren potentiates the antihypertensive effects of calcium channel blockers, diuretics, ACE inhibitors or AT1 receptor antagonists.34,35 In addition, aliskiren reduced proteinuria and delayed the progression of renal dysfunction if compared with placebo.4 More recently, the treatment with aliskiren alone or in combination with AT1 receptor antagonism significantly reduced proteinuria in patients with non-diabetic CKD.36

Experimental studies have shown that surgical removal of large amounts of the renal parenchyma increases the expression of several proinflammatory genes and stimulates infiltration of the remaining renal tissue by macrophages.37,38 According to these findings, the present study found a significant increase of the urinary concentrations of IL-1ß, IL-6, IL-10 and TGF-ß following ¾ nephrectomy in rats.

However, the profile of cytokines differed according to the treatment. For instance, the AT1 antagonist candesartan reduced all evaluated molecules (IL-1ß, IL-6, TGF-ß and IL-10). In experimental models of CKD, the treatment with candesartan significantly decreased the mRNA for TGF-ß in renal tissue and by so doing slowed the progression of renal injury.39-42 Candesartan administration also reduced renal IL-1ß and IL-6 levels and improved renal function in Zucker obese rats.42 In diabetic patients, treatment with candesartan reduced serum levels of IL-6.41

Less pronounced changes in cytokine profile were elicited by enalapril administration, since only urinary IL-6 concentrations were significantly reduced. Similarly, Ding et al.43 showed a reduction of renal expression of IL-6 in Wistar rats submitted to unilateral right nephrectomy.

Alternatively, in rats subjected to subtotal nephrectomy, Ghosh et al.44 reported a reduction of IL-1ß and TGF-ß levels following the treatment with enalapril. The results obtained with aliskiren differed somewhat from the other treatments. The renin inhibitor reduced urinary concentrations of pro-inflammatory cytokines, IL-1ß and IL-6, and did not change TGF-ß levels.

Moreover, aliskiren was the only treatment that increased urinary levels of IL-10. According to our findings, previous studies also reported the effects of aliskiren in pro-inflammatory cytokines.4,5,45-48 Matavelli et al.45 showed that the treatment of diabetic rats with aliskiren reduced IL-6 and TNF-a levels in renal interstitium by decreasing renal concentrations of Ang II. Accordingly, Wang et al.46 reported that aliskiren prevented the increase in the levels of renal tissue mRNA for the expression of proinflammatory cytokines (TNFa and IL-1ß), attenuated albuminuria and glomerulosclerosis in a mice model of diabetic nephropathy.

In contrast to our data, other investigators found that aliskiren reduced renal TGF-ß levels in a mice model of progressive renal fibrosis48 and decreased urinary concentration of this cytokine in patients with nondiabetic kidney diseases.47 These divergent findings related to TGF-ß might be due to differences in experimental models and/or in the degree of fibrosis.

However, this study is the first showing an elevation of urinary IL-10 following aliskiren administration. It has been previously reported that IL-10 exerts anti-inflammatory effects in other experimental models different from CKD.21-23 In these studies, anti-inflammatory pharmaceuticals and/or phytotherapy products increased IL-10 levels as part of their mechanism of action.21-23 We might speculate that the elevation in IL-10 levels could contribute, at least in part, to the beneficial effects of renin inhibitors also at renal tissue. Further studies are necessary to support our hypothesis.

We are aware of the limitations of our study. The main point is that we did not evaluate the mechanisms beyond the interactions between RAS blockers and urinary cytokines. In addition, our study did not allow us to precisely determine the role of urinary cytokines in CKD pathogenesis. On the other hand, some aspects may strength our findings, including the rigorous experimental protocols and the low intra-assay variability for cytokines measurements.

In conclusion, this study showed that ¾ nephrectomy resulted in changes in renal function parameters, elevated blood pressure, produced kidney tissue injury and increased urinary concentrations of pro-inflammatory cytokines (IL-1ß and IL-6), a mediator of fibrosis (TGF-ß) and an anti-inflammatory cytokine (IL-10). The pharmacological blockade of RAS at different levels improved renal function, reduced blood pressure and altered the profile of urinary cytokines.

All treatments reduced the pro-inflammatory cytokine IL-6. However, only renin inhibition was able to increase the anti-inflammatory mediator, i.e., IL-10. Our results did not allow the identification of specific mechanisms of action of each treatment, but suggest that local release of molecules related to inflammation and fibrosis may vary according to the site of RAS blockade and these differences may contribute to the effects of these medications in CKD.


This study was partially supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq, Brazil - grants number 470472/2014-6 and 460334/2014-0), Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG, Brazil - grant number CDS - PPM-00555-15), and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).


Tylicki L, Lizakowski S, Rutkowski B. Renin-angiotensin-aldosterone system blockade for nephroprotection: current evidence and future directions. J Nephrol 2012;25:900-10.Link DOILink PubMed
Verdecchia P, Gentile G, Angeli F, Reboldi G. Beyond blood pressure: evidence for cardiovascular, cerebrovascular, and renal protective effects of renin-angiotensin system blockers. Ther Adv Cardiovasc Dis 2012;6:81-91. Link DOILink PubMed
Simões E, Silva AC, Flynn JT. The renin-angiotensin-aldosterone system in 2011: role in hypertension and chronic kidney disease. Pediatr Nephrol 2012;10:1835-45.Link DOI
Friedrich S, Schmieder RE. Review of direct renin inhibition by aliskiren. J Renin Angiotensin Aldosterone Syst 2013;14:193-6. Link DOILink PubMed
Bhatti AB, Gazali ZA. Can Aliskiren be Considered as a New Novel Drug for Hypertension? Cureus 2015;7:e375. Link DOI
Panichi V, Migliori M, De Pietro S, Taccola D, Bianchi AM, Giovannini L, et al. C-reactive protein and interleukin-6 levels are related to renal function in predialytic chronic renal failure. Nephron 2002;91:594-600. PMID: 12138260 Link PubMedLink DOI
Oberg BP, McMenamin E, Lucas FL, McMonagle E, Morrow J, Ikizler TA, et al. Increased prevalence of oxidant stress and inflammation in patients with moderate to severe chronic kidney disease. Kidney Int 2004;65:1009-16.Link DOILink PubMed
Stenvinkel P, Ketteler M, Johnson RJ, Lindholm B, Pecoits-Filho R, Riella M, et al. IL-10, IL-6, and TNF-alpha: central factors in the altered cytokine network of uremia-the good, the bad, and the ugly. Kidney Int 2005;67:1216-33.Link PubMedLink DOI
Vianna HR, Soares CM, Silveira KD, Elmiro GS, Mendes PM, de Sousa Tavares M, et al. Cytokines in chronic kidney disease: potential link of MCP-1 and dyslipidemia in glomerular diseases. Pediatr Nephrol 2013;28:463-9.Link DOILink PubMed
Pereira AB, Teixeira AL, Rezende NA, Pereira RM, Miranda DM, Oliveira EA, et al. Urinary chemokines and anti-inflammatory molecules in renal transplanted patients as potential biomarkers of graft function: a prospective study. Int Urol Nephrol 2012;44:1539-48.Link DOILink PubMed
Stangou M, Alexopoulos E, Papagianni A, Pantzaki A, Bantis C, Dovas S, et al. Urinary levels of epidermal growth factor, interleukin-6 and monocyte chemoattractant protein-1 may act as predictor markers of renal function outcome in immunoglobulin A nephropathy. Nephrology (Carlton) 2009;14:613-20.Link DOILink PubMed
Macconi D, Remuzzi G, Benigni A. Key fibrogenic mediators: old players. Renin-angiotensin system. Kidney Int Suppl (2011) 2014;4:58-64.Link DOILink PubMed
Brewster UC, Perazella MA. The renin-angiotensin-aldosterone system and the kidney: effects on kidney disease. Am J Med 2004;116:263-72. Link PubMedLink DOI
Chen D, Coffman TM. AT1 Angiotensin receptors-vascular and renal epithelial pathways for blood pressure regulation. Curr Opin Pharmacol 2015;21:122-6.Link DOILink PubMed
Navar LG. Intrarenal renin-angiotensin system in regulation of glomerular function. Curr Opin Nephrol Hypertens 2014;23:38-45.Link DOILink PubMed
Thethi T, Kamiyama M, Kobori H. The link between the renin-angiotensin-aldosterone system and renal injury in obesity and the metabolic syndrome. Curr Hypertens Rep 2012;14:160-9.Link DOILink PubMed
Wong C, Kanetsky P, Raj D. Genetic polymorphisms of the RAS-cytokine pathway and chronic kidney disease. Pediatr Nephrol 2008;23:1037-51.Link DOILink PubMed
Ruiz-Ortega M, Lorenzo O, Suzuki Y, Rupérez M, Egido J. Proinflammatory actions of angiotensins. Curr Opin Nephrol Hypertens 2001;10:321-9.Link DOILink PubMed
Simões e Silva AC, Silveira KD, Ferreira AJ, Teixeira MM. ACE2, angiotensin-(1-7) and Mas receptor axis in inflammation and fibrosis. Br J Pharmacol 2013;169:477-92.Link PubMedLink DOI
Tsakas S, Goumenos DS. Accurate measurement and clinical significance of urinary transforming growth factor-beta1. Am J Nephrol 2006;26:186-93. Link PubMedLink DOI
Schulze-Topphoff U, Shetty A, Varrin-Doyer M, Molnarfi N, Sagan SA, Sobel RA, et al. Laquinimod, a quinoline-3-carboxamide, induces type II myeloid cells that modulate central nervous system autoimmunity. PLoS One 2012;7:e33797.Link PubMedLink DOI
Azevedo MS, Zhang W, Wen K, Gonzalez AM, Saif LJ, Yousef AE, et al. Lactobacillus acidophilus and Lactobacillus reuteri modulate cytokine responses in gnotobiotic pigs infected with human rotavirus. Benef Microbes 2012;3:33-42.Link DOILink PubMed
Zarogiannis SG, Noah JW, Jurkuvenaite A, Steele C, Matalon S, Noah DL. Comparison of ribavirin and oseltamivir in reducing mortality and lung injury in mice infected with mouse adapted A/California/04/2009 (H1N1). Life Sci 2012;90:440-5.Link PubMedLink DOI
Ormrod D, Miller T. Experimental uremia. Description of a model producing varying degrees of stable uremia. Nephron 1980;26:249-54.Link PubMedLink DOI
Samad MA, Kim UK, Kang JJ, Ke Q, Kang PM. Endothelin A receptor antagonista, atrasentan, attenuated renal and cardiac dysfunction in Dahl salt-hypertensive rats in a blood pressure independ manner. PLoS One 2015;10:e0121664.Link PubMedLink DOI
Kumar KV, Satyanarayana S, Kumar KE. Evaluation of enalapril affecting the renin-angiotensin system in normal and stree-induced rats based on urinary metabolites of amines and cortisol. J Renin Angiotensin Aldosterone Syst 2013;14:34-40.Link DOILink PubMed
Lin L, Philips WE, Manning RD. Intrarenal Angiotensin II is associated with inflammation, renal damage and dysfunction in Dahl-sensitive hypertension. J Am Soc Hypertens 2009;3:306-14. Link DOILink PubMed
De Melo W, Rivera M, Rabell A, Gerena Y. Aliskiren, at low doses, reduces the electrical remodeling in the heart of the TGR(mRen2)27 rat independently of blood pressure. J Renin Aldosterone Syst 2013;14:23-33.Link DOI
Ziypak T, Halici Z, Alkan E, Akpinar E, Polat B, Adanur S, et al. Renoprotective effect of aliskiren on renal ischemia/reperfusion injury in rats: electron microscopy and molecular study. Ren Fail 2015;37:343-54.Link DOILink PubMed
Bouby N, Bachmann S, Bichet D, Bankir L. Effect of water intake on the progression of chronic renal failure in the 5/6 nephrectomized rat. Am J Physiol 1990;258:F973-9.Link PubMed
Kwon TH, Frøkiaer J, Knepper MA, Nielsen S. Reduced AQP1, -2, and -3 level in kidneys of rats with CRF induced by surgical reduction in renal mass. Am J Physiol 1998;275:724-41.
Chamberlain RM, Shirley DG. Time course of the renal functional response to partial nephrectomy: measurements in conscious rats. Exp Physiol 2007;92:251-62.Link PubMedLink DOI
Matsukawa T, Miyamoto T. Angiotensin II-stimulated secretion of arginine vasopressin is inhibited by atrial natriuretic peptide in humans. Am J Physiol Regul Integr Comp Physiol 2011;300:R624-9.Link PubMedLink DOI
Townsend RR, Forker AD, Bhosekar V, Yadao A, Keefe DL. Comparison of aliskiren/hydrochlorothiazide combination therapy and amlodipine monotherapy in patients with stage 2 systolic hypertension and type 2 diabetes mellitus. J Clin Hypertens (Greenwich) 2011;13:889-97.Link DOILink PubMed
Axthelm C, Sieder C, Meister F, Kaiser E. Efficacy and tolerability of the single-pill combination of aliskiren 300 mg/amlodipine 10 mg in hypertensive patients not controlled by olmesartan 40 mg/amlodipine 10 mg. Curr Med Res Opin 2012;28:69-78.Link PubMedLink DOI
Woo KT, Choong HL, Wong KS, Tan HK, Foo M, Fook-Chong S, et al. Aliskiren and losartan trial in non-diabetic chronic kidney disease. J Renin Angiotensin Aldosterone Syst 2014;15:515-22.Link DOILink PubMed
Taal MW, Zandi-Nejad K, Weening B, Shahsafaei A, Kato S, Lee KW, et al. Proinflammatory gene expression and macrophage recruitment in the rat remnant kidney. Kidney Int 2000;58:1664-76.Link PubMedLink DOI
Hisada Y, Sugaya T, Yamanouchi M, Uchida H, Fujimura H, Sakurai H, et al. Angiotensin II plays a pathogenic role in immune-mediated renal injury in mice. J Clin Invest 1999;103:627-35.Link DOILink PubMed
Noda M, Matsuo T, Fukuda R, Ohta M, Nagano H, Shibouta Y, et al. Effect of candesartan cilexetil (TCV-116) in rats with chronic renal failure. Kidney Int 1999;56:898-909.Link PubMedLink DOI
Higashi K, Oda T, Kushiyama T, Hyodo T, Yamada M, Suzuki S, et al. Additive antifibrotic effects of pioglitazone and candesartan on experimental renal fibrosis in mice. Nephrology (Carlton) 2010;15:327-35.Link DOILink PubMed
Pavlatou MG, Mastorakos G, Margeli A, Kouskouni E, Tentolouris N, Katsilambros N, et al. Angiotensin blockade in diabetic patients decreases insulin resistance-associated low-grade inflammation. Eur J Clin Invest 2011;41:652-8.Link DOILink PubMed
Ecelbarger CM, Rash A, Sinha RK, Tiwari S. The effect of chronic candesartan therapy on the metabolic profile and renal tissue cytokine levels in the obese Zucker rat. Mediators Inflammation 2010;2010:841343.Link PubMedLink DOI
Ding LH, Liu D, Xu M, Liu H, Wu M, Tang RN, et al. Enalapril inhibits tubulointerstitial inflammation and NLRP3 inflammasome expression in BSA-overload nephropathy of rats. Acta Pharmacol Sin 2014;35:1293-301.Link PubMedLink DOI
Ghosh SS, Krieg R, Massey HD, Sica DA, Fakhry I, Ghosh S, et al. Curcumin and enalapril ameliorate renal failure by antagonizing inflammation in 5/6 nephrectomized rats: role of phospholipase and cyclooxygenase. Am J Physiol Renal Physiol 2012;302:439-54.Link DOI
Matavelli LC, Huang J, Siragy HM. Combined aliskiren and amlodipine reduce albuminuria via reduction in renal inflammation in diabetic rats. J Cardiovasc Pharmacol 2012;59:281-7.Link DOILink PubMed
Wang W, Qiu L, Howard A, Solis N, Li C, Wang X, et al. Protective effects of aliskiren and valsartan in mice with diabetic nephropathy. J Renin Angiotensin Aldosterone Syst 2014;15:384-95.Link DOILink PubMed
Lizakowski S, Tylicki L, Renke M, Rutkowski P, Heleniak Z, Slawinska-Morawska M, et al. Aliskiren and perindopril reduce the levels of transforming growth factor-ß in patients with non-diabetic kidney disease. Am J Hypertens 2012;25:636-9.Link DOILink PubMed
Gross O, Girgert R, Rubel D, Temme J, Theissen S, Müller GA. Renal protective effects of aliskiren beyond its antihypertensive property in a mouse model of progressive fibrosis. Am J Hypertens 2011;24:355-61.Link DOILink PubMed

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