Preconditioning by Moderate-Intensity Exercise Prevents Gentamicin-Induced Acute Kidney Injury

Abstract

A strict correlation among proximal tubule epithelial cell dysfunction, proteinuria, and modulation of the Renin-Angiotensin System and Kalikrein-Kinin System are crucial factors in the pathogenesis of Acute Kidney Injury (AKI). In this study, we investigated the potential protective effect of preconditioning by moderate-intensity aerobic exercise on gentamicin-induced AKI. Male Wistar rats were submitted to a moderate-intensity treadmill exercise protocol for 8 weeks, and then injected with 80 mg/kg/day s.c. gentamicin for 5 consecutive days. Four groups were generated: 1) NT+SAL (control); 2) NT+AKI (non-trained with AKI); 3) T+SAL (trained); and 4) T+AKI (trained with AKI). The NT+AKI group presented: 1) impairment in glomerular function parameters; 2) increased fractional excretion of Na ⁺ , K ⁺ , and water; 4) proteinuria and increased urinary γ-glutamyl transferase activity (a marker of tubular injury) accompanied by acute tubular necrosis; 5) an increased renal angiotensin-converting enzyme and bradykinin B1 receptor mRNA expression. Interestingly, the preconditioning by moderate-intensity aerobic exercise attenuated all alterations observed in gentamicin-induced AKI (T+AKI group). Taken together, our results show that the preconditioning by moderate-intensity aerobic exercise ameliorates the development of gentamicin-induced AKI. Our findings help to expand the current knowledge regarding the effect of physical exercise on kidneys during physiological and pathological conditions.

 

MissingLinkText

Keywords

acute kidney injury - gentamicin - moderate-intensity aerobic exercise - proteinuria - Renin-Angiotensin System - Kallikrein-Kinin System

Introduction

Acute kidney injury (AKI) is a leading cause of morbidity and mortality worldwide [1] [2]. AKI episodes are characterized by transient kidney dysfunction caused by different etiologies [3] [4] [5] [6]. The use of aminoglycosides (AG), such as gentamicin, to treat life-threatening infections is an important etiological factor of AKI [3] [7] [8] [9]. It has been shown that 5–10% of adult patients and 20–33% of non-critical ill children treated with AGs develop AKI [3] [7] [8] [9]. AG enters proximal tubule epithelial cells (PTECs) through receptor-mediated endocytosis, accumulating in high concentrations in its intact form, which in turn leads to PTECs death and tubular injury [7] [10] [11]. However, the mechanisms underlying the gentamicin-induced PTEC injury are still poorly understood.

It is known that PTEC injury correlates with the development of acute tubular necrosis (ATN), tubular dysfunction, and proteinuria in AKI [12] [13]. Additionally, there is an association between these factors and the abnormal activation of components from the renin-angiotensin system (RAS) and/or kallikrein-kinin system (KKS) in different forms of AKI [14] [15] [16] [17]. Ali and Bashir [18] showed increased plasma ACE activity in gentamicin-induced AKI. Furthermore, Heeba [19] showed that blocking the angiotensin II receptor (AT₁R) with losartan (a well-known angiotensin receptor blocker - ARB) ameliorated ATN and albuminuria in gentamicin-induced AKI. On the other hand, Bledsoe et al. [20] showed that the infusion of tissue kallikrein ameliorated tubular injury and cell apoptosis observed in gentamicin-induced AKI through the activation of bradykinin B2 receptor (B₂R). These data indicate the potential involvement of RAS and KKS in the development of gentamicin-induced AKI. However, the therapeutical use of ARBs or ACE inhibitors is not recommended during an AKI episode because of their adverse effects on renal hemodynamics, further disturbing glomerular flow rate (GFR) levels [14]. Therefore, it becomes attractive to use alternative therapeutic strategies to modulate intrarenal RAS and/or KKS as well as the kidney’s responses prior to an AKI episode, which in turn would prevent the development of gentamicin-induced AKI.

Since the levels of renal injuries observed during AKI onset depend on the background susceptibility and the state of the renal microenvironment [12] [13], systemic adaptations following preconditioning by aerobic exercise appear to be a promising candidate. Beyond the known effects of skeletal muscles, regular physical activity, such as aerobic exercise, also promotes several positive systemic adaptations in blood flow, cell metabolism, and immunological responses in different systems, including the kidneys [21]. It has been shown that physical exercise acts as an adjuvant in the treatment of many disorders [22] [23] [24] [25]. Some studies have shown that moderate-intensity aerobic exercise (MIAE) promotes protective effects in AKI and CKD animal models [26] [27] [28] [29]. De Lima et al. [27] demonstrated that ATN and increased active caspase-3 expression were prevented following preconditioning by MIAE in ischemia/reperfusion (I/R)-induced AKI. Additionally, Francescato et al. [28] showed that tubular injury, inflammation, and fibrosis were reduced due to an increase in renal nitric oxide (NO) after preconditioning by MIAE in cisplatin-induced AKI. Furthermore, previous work showed that MIAE modulates RAS and KKS components in skeletal muscle, lung, and liver [30] [31] [32] [33]. Based on the above, we hypothesized that preconditioning by MIAE could modulate the components of intrarenal RAS and KKS, which in turn could prevent the development of the tubular injury and proteinuria observed in gentamicin-induced AKI.

In the present work, we aimed to study the potential protective effect of preconditioning by MIAE on tubular injury observed gentamicin-induced AKI and verify its possible correlation with changes in intrarenal RAS and KKS. To this purpose, we used male Wistar rats subjected or not to an MIAE protocol for 8 consecutive weeks. Then, AKI was induced by daily subcutaneous injections of gentamicin (80 mg/kg/day) for 5 consecutive days. Our results showed that preconditioning by MIAE attenuated the tubular injury and proteinuria observed in gentamicin-induced AKI. These protective effects correlated with the inhibition of renal ACE and B₁R. These findings shed new light on the potential reno-protective effects of aerobic exercise under pathological conditions.

 

MissingLinkText

Materials and Methods

Animals

Male Wistar rats (250–300 g) were obtained from the Central Animal Facility of Federal University of Minas Gerais. All procedures were conducted according to protocols approved by the Institutional Ethics Committee (CEUA-UFMG#59/2015).

 

MissingLinkText

Preconditioning by moderate-intensity aerobic exercise (MIAE)

Rats were trained on a treadmill (Gaustec Magnetismo, MG, Brazil) according to a training protocol described by Previero et al. [34]. The efficacy of the training protocol was evaluated by applying three maximum progressive effort tests (MPET) [35]. The progression of the training protocol is summarized in [Table 1]. MPET allows for the evaluation of total time of exercise (TTE), maximum running speed (MRS), distance (D), and workload (W), which is calculated as W (k x gm)=body weight (kg) x TTE (min) x speed on the treadmill when fatigue is reached (m/min) x grade of treadmill inclination [36].

Table 1 Protocol of moderate intensity aerobic training.

Training Progression
MEPT	1st week	2nd week	3rd week	4th week
1st	28% MRS/30–40 min	44% MRS/45 min	65% MRS/50 min	65% MRS 60 min
	5–8th week
2nd	65% of MRS*/60 min
3rd	65% of MRS*/60 min

The training protocol was adapted from Priviero et al. [34]. *Maximal run speed (MRS) was adjusted according to running performance achieved at 2^nd MPET.

 

MissingLinkText

Induction of gentamicin-induced AKI after preconditioning by MIAE

After completing the 8-week MIAE training protocol, rats were housed individually in metabolic cages with free access to water and chow. Four experimental groups were generated: 1) non-trained injected with saline (NT+SAL); 2) non-trained injected with gentamicin (NT+AKI); 3) trained injected with saline (T+SAL); and 4) trained injected with gentamicin (T+AKI). Gentamicin-treated groups (NT+AKI and T+AKI) received gentamicin (Gentotec, 80 mg/kg/ day, 0.1 ml/100 g body weight, subcutaneously) for 5 days. Saline (0.9% NaCl) was used as a vehicle. After treatment, 24-hour urine was collected for further analysis. Rats were anesthetized (15 mg/kg ketamine and 7.5 mg/kg xylazine, intraperitoneally) and a blood sample was collected from the inferior vena cava. Under anesthesia, rats were euthanized through diaphragm perforation. Soleus muscles, kidneys, plasma, and urine were stored at − 80°C until use.

 

MissingLinkText

Cardiovascular parameters

Systolic, diastolic, and mean arterial pressures (SAP, DAP, and MAP, respectively) and heart rate were measured using tail-cuff plethysmography (CODA Noninvasive Blood Pressure Monitor - Kent Scientific Corporation, Connecticut, USA).

 

MissingLinkText

Assessment of renal function

Urine flow was determined volumetrically, and GFR was estimated by creatinine clearance (C_Cr) [17] [37]. Creatinine concentrations were determined colorimetrically using a commercial kit (Bioclin/Quibasa, MG, Brazil). Proteinuria and γ-glutamyl transferase enzyme activity (γ-GT) were measured using commercial kits (Labtest, MG, Brazil). Sodium and potassium concentrations were measured by flame photometry (CELM, FC 280, MG, Brazil). Osmolality was determined by freezing point osmometry (Micro-osmette, Precision System Inc, MA, USA).

 

MissingLinkText

Measurement of citrate synthase activity

Citrate Synthase (CS) activity in soleus muscle homogenates was measured as previously described [38]. The CS assay consisted of the incubation of homogenate (5 µl) with a buffered solution (50 mM Tris-HCl containing 5 mM EDTA, 0.05% Triton X-100, 30 mM Acetil-CoA, 10 mM DTNB, pH 8.1).

 

MissingLinkText

Histological analysis

Kidneys were fixed in 10% buffered formaldehyde and embedded in paraffin. 4 μm kidney sections were used for Hematoxylin-Eosin staining. Analysis was carried out in a microscope (Axiolab, Carl Zeiss, Oberkochen, Germany) at a magnification of×40 under blinded conditions. Morphometric analysis was performed using NIH ImageJ software (version 1.6.0). The total glomerular area (area by glomerulus), glomerular tuft area (% of total glomerular area) and Bowman’s space area (% of total glomerular area), as well as glomerular cellularity (%), number of tubular cells (cells per field), vacuolization rate (vacuolization area normalized by tubular cells), tubular pyknotic cells (%) and accumulation of interstitial cells (%) were analyzed. It is important to mention that all morphometric analyses were performed in a double-blind manner.

 

MissingLinkText

Extraction of renal mRNA and analysis of gene expression

Renal gene expression of angiotensin-converting enzyme (ACE) and angiotensin-converting enzyme 2 (ACE2) enzymes, angiotensin II type 1 receptor (AT₁R), Mas receptor (MasR), bradykinin B1 receptor (B₁R), and B2 receptor (B₂R) were analyzed by real-time PCR. Renal mRNA was extracted using Trizol reagent (Life Technologies, Carlsbad, CA, USA) according to the manufacturer’s protocol, and mRNA concentration was determined in a NanoVue Plus Spectrophotometer (GE Healthcare, Piscataway, NJ, USA). Reverse transcription was performed using 1 µg of total pure mRNA, 200 units of reverse transcriptase, 100 mM DTT (dithiothreitol, 1.0 µL), 5x reverse transcription buffer (2.5 µL), 10 mM dNTPs (1.8 µL), 10000 units of RNAsin ( 0.2 µL) and 50 ng/ml of oligo (dT) (1.0 µL). The resultant cDNA was used for real-time PCR. Specific sense and anti-sense primers’ sequences were: ACE (5’-CTTCACTGACCAAAAGCTGCG-3’ and 5’-CCTAGGGTCTGTACGGATCCG-3’); ACE2: 5’-GTGGAGGTGGATGGTCTTTCA-3’ and 5’-TTGGTCCACTGTTCTCTGGGA-3’); AT₁R: 5’-TCTCAGCATCGATCGCTACCT-3’ and 5’-AGGCGAGACTTCATTGGGTG-3’); Mas: 5’-TGACCATTGAACAGATTGCCA-3’ and 5’-TGTAGTTTGTGACGGCTGGTG-3’); B₁R (5’-AACATCGGGAACCGTTTCAAC-3’ and 5’-CACCCGGCAGAGGTCAGTT-3’); and B₂R (5’-GCCTCCCTTCCGGCATATT-3’ and 5’-TCATAAAAGGCAGACCATTTGG-3’). Real-time PCR was carried out on an ABI PRISM 7000 Sequence Detection System (Applied Biosystems, California, USA) with SYBR Green PCR Master Mix (Applied Biosystems, California, USA). The relative levels of gene expression were determined using the comparative threshold cycle method and normalized to GAPDH expression.

 

MissingLinkText

Statistical analysis

Results are expressed as the means±SEM. After confirmation of normal distribution by the Kolmogorow-Smirnov test, the data were analyzed by two-way ANOVA followed by the Bonferroni test. Statistical analyses were performed using GraphPad Prism, version 8 for Windows (GraphPad Software, San Diego, CA).

 

MissingLinkText

 

MissingLinkText

Results

Protective effect of preconditioning by moderate-intensity aerobic exercise on the glomerular and tubular dysfunctions observed in gentamicin-induced acute kidney injury

Initially, we randomly divided the rats into two distinct groups: 1) non-trained rats, sedentary animals; and 2) trained rats, animals submitted to MIAE protocol for 8 consecutive weeks ([Table 1]). At this point, MPETs were assessed ([Fig. 1]). TTE, MRS, D, and W were significantly increased after the 8^th week of applied training protocol ([Fig. 1a-d]). In addition, we observed a reduction in heart rate without any changes in SAP, DAP, or MAP ([Fig. 2a-d]).

Fig. 1 The effect of preconditioning by moderate-intensity aerobic exercise on maximum progressive effort tests. Male Wistar rats (8–10 weeks) were submitted to two aerobic training protocols (using a treadmill) for 8 consecutive weeks: 1) non-trained group (5 m/min, 5 min/day, 5 days/week, n=13), and 2) trained group (28–65% of maximum running speed, 60 min/day, 5 days/week, n=13). (a-d) Assessment of different parameters of maximum progressive effort tests (MPETs). (a) Time of training. (b) Distance. (c) Maximal running speed. (d) Workload. In Graph a-d: the black circles denote the 1^st MPET (period before the application of the training protocol); the black triangles denote the 2^nd MPET; and black squares denote the 3^rd MPET (period after the application of the training protocol). Data were presented in the mean±standard error of the mean (SEM).

Fig. 2 The effect of preconditioning by moderate-intensity aerobic exercise on cardiovascular parameters. Male Wistar rats (8–10 weeks) were submitted to two aerobic training protocols (using a treadmill) for 8 consecutive weeks: 1) non-trained group (5 m/min, 5 min/day, 5 days/week, n=13), and 2) trained group (28–65% of maximum running speed, 60 min/day, 5 days/week, n=13). In Graph a-d, the black circles denote the period before the application of the training protocol, while the black squares denote the period after the application of the training protocol. (a-d) Measurement of cardiovascular parameters. (a) Heart rate. (b) Systolic arterial pressure. (c) Diastolic arterial pressure. (d) Mean arterial pressure. The cardiovascular parameters were assessed by tail plethysmography. Data were presented in the mean±standard error of the mean (SEM).

[Fig. 3a] shows the AKI development protocol in non-trained and trained groups. We found that the trained rats presented higher CS activity (a marker of physical training) in soleus muscle extracts ([Fig. 3b]), indicating that the influence of preconditioning was maintained.

Fig. 3 The efficiency of preconditioning by moderate-intensity aerobic exercise after gentamicin-induced AKI. After the training protocols were applied to rats as depicted in [Fig. 1], the animals were separated to induce gentamicin-induced AKI generating four experimental groups (detailed in the Methods section): 1) SAL+NT (n=6); 2) AKI+NT (n=6); 3) SAL+T (n=6) and 4) AKI+T (n=7). (a) Experimental design. NT, non-trained rats; T, trained rats. (b) Measurement of citrate synthase activity in skeleton muscle after 5 days post-gentamicin daily injections. The white bar denotes rats injected with saline. The blue bar denotes rats injected with gentamicin. Data were presented in the mean±standard error of the mean (SEM).

No changes were observed in water intake among the experimental groups ([Fig. 4a]). Interestingly, NT+AKI and T+AKI groups had increased urinary volume (mL/24 h) and hydric balance (%); however, these effects were attenuated in the T+AKI group ([Fig. 4b, c]). Furthermore, no changes were observed in the osmolar clearance and free water clearance ([Fig. 4d, e]).

Fig. 4 The effect of preconditioning by moderate-intensity aerobic exercise on net renal function changed by gentamicin-induced AKI. The rats were submitted to moderate-intensity aerobic training protocols as depicted in [Table 1]. After the exercise training the animals were treated with gentamicin to develop AKI according to the experimental design shown in [Fig. 3a]: 1) SAL+NT (n=6); 2) AKI+NT (n=6); 3) SAL+T (n=6) and 4) AKI+T (n=7). NT, non-trained rats; T, trained rats. (a) Water intake. (b) Urinary volume. (c) Hydric balance. (d) Osmolar clearance (C_Osm). (e) Free water clearance (C_H2O). The white bar denotes rats injected with saline. The blue bar denotes rats injected with gentamicin. Data were presented in the mean±standard error of the mean (SEM).

Assessing the glomerular function, we observed higher levels of plasma creatinine concentration as well as a significant drop in C_Cr levels in the NT+AKI and T+AKI groups ([Fig. 5a, b]). Interestingly, these effects were attenuated by preconditioning with MIAE.

Fig. 5 The effect of preconditioning by moderate-intensity aerobic exercise on glomerular dysfunction triggered by gentamicin-induced AKI. The rats were submitted to moderate-intensity aerobic training protocols as depicted in [Table 1]. After the exercise training the animals were treated with gentamicin to develop AKI according to the experimental design shown in [Fig. 3a]: 1) SAL+NT (n=6); 2) AKI+NT (n=6); 3) SAL+T (n=6) and 4) AKI+T (n=7). NT, non-trained rats; T, trained rats. (a) Measurement of plasma creatinine. (b) Determination of creatinine clearance (C_Cr). The white bar denotes rats injected with saline. The blue bar denotes rats injected with gentamicin. Data were presented in the mean±standard error of the mean (SEM).

Assessing the tubular function by investigating the tubular handling of electrolytes and water, we did not observe any significant changes in urinary Na⁺ and K⁺ excretion in all experimental conditions ([Fig. 6a, b]). On the other hand, we found that the NT+AKI group had significantly higher levels of the fractional excretion of Na⁺ (FE_Na+), K⁺ (FE_K+), and water (FE_H2O) ([Fig. 6c-e]). However, these modifications were attenuated in the T+AKI group.

Fig. 6 The effect of preconditioning by moderate-intensity aerobic exercise on tubular dysfunction triggered by gentamicin-induced AKI. The rats were submitted to moderate-intensity aerobic training protocols as depicted in [Table 1]. After the exercise training the animals were treated with gentamicin to develop AKI according to the experimental design shown in [Fig. 3a]: 1) SAL+NT (n=6); 2) AKI+NT (n=6); 3) SAL+T (n=6) and 4) AKI+T (n=7). NT, non-trained rats; T, trained rats. (a-b) The measurement of ext-linknary mass of Na⁺ (a) and K⁺ (b). To determine tubular function were measured: (c) the fractional excretion of water (FE_H2O); (d) the fractional excretion of sodium (FE_Na+); and (e) the fractional excretion of potassium (FE_K+). The white bar denotes rats injected with saline. The blue bar denotes rats injected with gentamicin. Data were presented in the mean±standard error of the mean (SEM).

 

MissingLinkText

Preconditioning by moderate-intensity aerobic exercise attenuates both glomerular and tubular injuries observed in gentamicin-induced acute kidney injury

Next, we assessed proteinuria (a marker of renal disease) and urinary γ-GT activity (a marker of PTEC injury). Our results showed that proteinuria and urinary γ-GT activity were increased in both NT+AKI and T+AKI groups, but to a lesser extent in the T+AKI group ([Fig. 7a, b]).

Fig. 7 The effect of preconditioning by moderate-intensity aerobic exercise on the modulation of ext-linknary kidney injury markers by gentamicin-induced AKI. The rats were submitted to moderate-intensity aerobic training protocols as depicted in [Table 1]. After the exercise training the animals were treated with gentamicin to develop AKI according to the experimental design shown in [Fig. 3a]: 1) SAL+NT (n=6); 2) AKI+NT (n=6); 3) SAL+T (n=6) and 4) AKI+T (n=7). NT, non-trained rats; T, trained rats. (a) Determination of ext-linknary protein. (b) Measurement of γ-glutamyl transferase (γ-GT) activity, a proximal tubule epithelial cell injury marker. The white bar denotes rats injected with saline. The blue bar denotes rats injected with gentamicin. Data were presented in the mean±standard error of the mean (SEM).

[Fig. 8] shows the assessment of renal cortex structure. No modifications were observed among the experimental groups when assessing the total glomerular area, glomerular tuft area, Bowman’s space area, as well as glomerular and tubular cellularity ([Fig. 8a-f]). We observed increased rates of cellular vacuolization and pyknotic nuclei (which are characteristics of ATN) as well as an increased number of interstitial cells in the NT+AKI and T+AKI groups ([Fig. 8g-i]). However, these features were attenuated by previous moderate training (T+AKI group).

Fig. 8 The beneficial effect of preconditioning by moderate-intensity aerobic exercise on the kidney injury observed in gentamicin-induced AKI. The rats were submitted to moderate-intensity aerobic training protocols as depicted in [Table 1]. After the exercise training the animals were treated with gentamicin to develop AKI according to the experimental design shown in [Fig. 3a]: 1) SAL+NT (n=4); 2) AKI+NT (n=5); 3) SAL+T (n=4) and 4) AKI+T (n=5). (a) Representative images of 5-μm kidney slices stained with hematoxylin-eosin. Subpanel A shows SAL+NT; subpanel B shows AKI+NT; subpanel C shows SAL+T; subpanel D shows AKI+T. Cellular vacuolization is denoted by (*) and pyknotic nuclei is denoted by (arrows). Magnification 400X. Bar=50μm. Morphometric analysis has been performed showing: (b) glomerular total area; (c) glomerular tuft area; (d) Bowman space area; (e) Glomerular cellularity; (f) Number of tubular epithelial cells; (g) Tubular vacuolization; (h) Tubular pyknotic cells; (i) Interstitial cells. Circles denote the number of animals (n) analyzed. Data were presented in the mean±standard error of the mean (SEM).

 

MissingLinkText

Preconditioning by moderate-intensity aerobic exercise modulates components from RAS and KKS altered during gentamicin-induced acute kidney injury

[Fig. 9] shows the measurement of mRNA levels of renal RAS components. Our findings revealed that the NT+AKI, T+SAL, and T+AKI groups exhibited higher levels of ACE mRNA. However, this effect was less pronounced in the T+SAL and T+AKI groups ([Fig. 9a]). AT1R mRNA was significantly increased only in the T+AKI group ([Fig. 9b]). Conversely, no significant changes were observed in ACE2 and Mas receptor mRNA ([Fig. 9c, d]).

Fig. 9 The effect of preconditioning by moderate-intensity aerobic exercise on the modulation of RAS components by gentamicin-induced AKI. The rats were submitted to moderate-intensity aerobic training protocols as depicted in [Table 1]. After the exercise training the animals were treated with gentamicin to develop AKI according to the experimental design shown in [Fig. 3a]: 1) SAL+NT (n=6); 2) AKI+NT (n=6); 3) SAL+T (n=6) and 4) AKI+T (n=7). NT, non-trained rats; T, trained rats. Then, the measurement of mRNA expression on kidney samples through real-time PCR was carried out. (a) ACE mRNA. (b) ACE2 mRNA. (c) AT1R mRNA. (d) Mas mRNA. The white bar denotes rats injected with saline. The blue bar denotes rats injected with gentamicin. Data were presented in the mean±standard error of the mean (SEM).

Our results showed that the NT+AKI group had a higher mRNA expression for B₁R than the NT+SAL group ([Fig. 10a]). Interestingly, the MIAE was able to counteract this stimulatory effect induced by AKI. Additionally, we observed no changes in the mRNA expression of B₂R ([Fig. 10b]).

Fig. 10 The effect of preconditioning by moderate-intensity aerobic exercise on the modulation of KKS components by gentamicin-induced AKI. The rats were submitted to moderate-intensity aerobic training protocols as depicted in [Table 1]. After the exercise training the animals were treated with gentamicin to develop AKI according to the experimental design shown in [Fig. 3a]: 1) SAL+NT (n=6); 2) AKI+NT (n=6); 3) SAL+T (n=6) and 4) AKI+T (n=7). NT, non-trained rats; T, trained rats. Then, the measurement of mRNA expression on kidney samples through real-time PCR was carried out. (a) B1R mRNA. (b) B2R mRNA. The white bar denotes rats injected with saline. The blue bar denotes rats injected with gentamicin. Data were presented in the mean±standard error of the mean (SEM).

 

MissingLinkText

 

MissingLinkText

Discussion

In this present work, we found that the preconditioning by MIAE attenuated the development of renal dysfunction in gentamicin-induced AKI, associated with amelioration of tubular injury and proteinuria. This effect was correlated with a reduction of renal ACE and B₁R mRNA expression. These findings help elucidate the possible beneficial interactions between systemic adaptations following preconditioning by MIAE.

The exercise training protocol used in this study was effective. The improvement in physical performance observed in trained animals confirms that the velocity reached in the MPET is adequate as described by Priviero et al. [34]. CS enzyme is a marker of oxidative adaptation of skeletal muscle to aerobic training due to its role as a regulator of carbon input in the Krebs cycle [39]. Our data are in agreement with the study that demonstrates an improvement in aerobic capacity [40]. Herein, no changes were observed in arterial pressures. This observation corroborates the effect of aerobic physical training on blood pressure in normotensive animals and humans, which seems to be minimal or even non-existent [41]. On the other hand, we did observe a reduction in resting heart rate. Training-induced bradycardia may indicate some adaptation of the autonomic nervous system [42] or even intrinsic electrophysiological changes in the sinus node [43]. The reduction of heart rate has been considered a physiological marker for aerobic adaptation to training [44].

In our study, we employed the preconditioning by MIAE protocol to investigate the potential protective effects of aerobic exercise on kidneys. Our choice was based on several reports indicating the protective effects of MIAE on different diseases, including kidney disease [22] [23] [24] [25]. Additionally, it was observed that MIAE did not change renal O₂ supply, but it did increase kidney mitochondria density and function [45]. On the other hand, it has been shown that high-intensity aerobic exercise transiently reduces renal blood flow [46]. This could be dangerous during the development of AKI, usually associated with PTECs hypoxia, leading to a worsening outcome. Moreover, it has been shown that high-intensity physical activity, such as ultramarathons or strenuous physical exercise, induces muscle damage and AKI [47] [48] [49] [50] [51] [52].

Hungaro et al. [53] demonstrated that preconditioning by 4-week MIAE did not alter the glomerular dysfunction in LPS-induced AKI. On the other hand, a similar training protocol attenuated glomerular dysfunction observed in cisplatin- and I/R-induced AKI [27] [28]. Herein, the preconditioning by MIAE ameliorated the development of glomerular dysfunction observed in gentamicin-induced AKI. These apparent contrast effects may be explained by the origin site of injuries.

GFR decline could involve a tubuloglomerular feedback (TGF) mechanism [54]. Herein, the preconditioning by MIAE attenuated the impairment of electrolytes and water reabsorption in gentamicin-induced AKI. In this way, the recovery of PTEC tubular reabsorption of electrolytes reduces the electrolytes delivery into the distal nephron, inhibiting the TGF mechanism, and consequently, increasing the C_Cr levels. Accordingly, preconditioning by MIAE only recovers GFR levels in AKI animal models where amelioration of tubules is observed [27] [28] [53]. Thus, it is plausible to imagine that: 1) glomerular dysfunction observed in gentamicin-induced AKI is secondary to tubular dysfunction; 2) this renoprotective effect occurs mainly due to improvement in tubular function.

Tubular dysfunction correlates with tubular injury and proteinuria in AKI and CKD [12] [13] [17] [55]. Proteinuria is a good marker of kidney disease and an active factor in disease progression [56] [57]. Herein, our findings showed that preconditioning by MIAE attenuated the development of ATN and proteinuria in gentamicin-induced AKI, indicating that the protective effect on tubular injury occurs due to amelioration of proteinuria. Accordingly, it has been shown: 1) an association between proteinuria and tubular injury in subclinical AKI and established AKI [17] [28] [58] [59] [60]; 2) compounds with anti-proteinuric effect ameliorate the tubular injuries [60] [61].

What is the possible correlation between the development of proteinuria and ATN in gentamicin-induced AKI? It is known that gentamicin accumulates in PTECs through its internalization into lysosomes in a process dependent on megalin-mediated endocytosis [62] [63]. Balaha et al. [64], using a gentamicin-induced AKI in rats, showed that gentamicin increased megalin expression at mRNA and protein levels in renal tissue. This could per se form a dangerous loop in gentamicin-induced nephrotoxicity. In addition, it is known that gentamicin binding to megalin inhibits megalin-mediated albumin uptake in PTECs and placenta [65] [66]. This inhibitory effect leads to the development of proteinuria during AKI [64]. The importance of this process appears when megalin blockade reduced the internalization of gentamicin as well as its nephrotoxicity [67]. Interestingly, in different renal diseases where the cause is megalin deficiency, the main phenotype is proteinuria as well as the development of tubule-interstitial injury [68] [69]. In this way, it is plausible to imagine that proteinuria associated with impairment of renal protein transport could trigger the development of tubule-interstitial injury in gentamicin-induced AKI. In agreement with this hypothesis, we observed the development of proteinuria and ATN in our experimental model.

RAS and KKS components are involved in the development and progression of different forms of AKI [14] [15] [16] [17]. Different works showed that blockade of the classical arm of RAS [18] [19] [70] [71] or activation of the alternative arm of RAS [4] [72] attenuates the gentamicin-induced AKI. Regarding KKS, Bledsoe et al. [20] showed the activation of B₂R ameliorated tubular injury induced by gentamicin. On the other hand, to our knowledge, no report has described the role of B₁R on gentamicin-induced AKI yet. Moreover, higher levels of angiotensin II and bradykinin impair the tubular protein uptake by PTECs [60] [73], which contributes to proteinuria and tubular injury. So, all these findings suggest that gentamicin enhances intrarenal RAS and KKS, and then promotes the development of ATN and proteinuria. Interestingly, our work is the first to describe the modulatory effect of MIAE on intrarenal RAS and KKS components. Our results showed that preconditioning by MIAE attenuated the increase of ACE and B1R mRNA expression triggered by gentamicin. In agreement with these findings, it has been proposed that MIAE modulates systemic and local RAS components in skeletal muscle, lungs, and liver [30] [31] [32] [33]. Altogether, these results allow us to suggest that the protective effects of MIAE-induced renal adaptations avoid the upregulation of intrarenal RAS and KKS triggered by gentamicin.

One question arises: what is the proposed mechanism for the protective direct effects of preconditioning by MIAE on kidneys during gentamicin-induced AKI? It is known that the common adaptations to MIAE lead to the maintenance of renal blood flow as well as renal O₂ supply [74]. In addition, other MIAE-induced renal adaptations are the increase of mitochondria biogenesis and activity as well as an increased of NO in the renal cortex of humans and rodents [45]. These effects are correlated with an increased life span and the tightrope test. Herein, higher CS activity was observed in skeletal muscle indicating the maintenance of MIAE-induced systemic adaptation even after the exercise period. Since it has been reported that gentamicin-induced PTEC injury involves mitochondrial dysfunction and PTEC death [7] [10] [11] and AKI onset depends on the balance between the intensity of injury and effective recovery phase [12] [13], the MIAE-induced renal adaptations may reduce the impact of gentamicin-induced mitochondrial dysfunction favoring the acceleration of recovering phase during the AKI episode. Moreover, it is worth mentioning that MIAE also stimulates cellular turnover as well as an anti-inflammatory microenvironment in different systems [21].

Gentamicin-induced AKI is observed in non-critical children and neonates as well as adults [3]. Zappitelli et al. [9], in a retrospective cohort study comprising ~8-years old 557 children, showed that 20–30% presented AKI after gentamicin treatment through the pediatric Risk, Injury, Failure, Loss, End Stage Kidney Disease (pRIFLE) and Acute Kidney Injury Network (AKIN) definitions. Huang et al. [8], in another retrospective study with 8,049 patients, showed that 6.14% presented AKI. The authors identified several risk factors involved in the development of AKI where the precondition of patients can determine AKI severity. Interestingly, Costanti-Nascimento et al. [75] proposed the prescription of moderate and regular aerobic exercise for patients who are at risk of developing AKI and for those diagnosed with AKI. In this present study, we observed that preconditioning by MIAE attenuated the development of gentamicin-induced AKI and reduced kidney injury biomarkers. Altogether, these findings allow us to suggest that regular aerobic exercise (moderated intensity) may contribute to reducing AKI severity in patients under antibiotic therapies, and consequently, avoiding AKI progression to CKD.

Possible limitations of our study might lie in the fact that the lack of a complete adaptation of rats to treadmill could reduce the final number of samples available for further analysis. In addition, despite CS activity in the skeletal muscle being a marker of systemic adaptation to MIAE, our data do not allow us to conclude that the same extent of modifications occur in the renal parenchyma. Limitations such as the assessment of renal functional parameters only on the 5^th day after the initial injection of gentamicin made it impossible to precisely determine what phase of AKI the MIAE-induced systemic adaptation could be playing a role. After all, the RAS and KKS components in this study were assessed only by qRT-PCR, which makes it hard to state that the functionality of the components is directly correlated to protein expression.

In conclusion, our results show that the preconditioning by MIAE led to renal adaptations that reduce the susceptibility to the development of ATN and proteinuria triggered by gentamicin. Our study is the first to show that this protective MIAE-induced renal adaptation involves the modulation of intrarenal RAS and KKS by inhibiting ACE and B₁R expression. Our findings highlight the importance of MIAE bringing the practice of physical exercise as a complementary strategy to prevent the development of AKI in individuals under antibiotic therapy. By reducing the number of AKI episodes in the population, the precondition by MIAE will contribute to preventing AKI progression to CKD and the development of other chronic degenerative diseases.

 

MissingLinkText

 

MissingLinkText

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Kellum JA, Romagnani P, Ashuntantang G. et al. Acute kidney injury. Nat Rev Dis Primers 2021; 7: 52
• 2 Kellum JA, Ronco C, Bellomo R. Conceptual advances and evolving terminology in acute kidney disease. Nat Rev Nephrol 2021; 17: 493-502
• 3 McWilliam SJ, Antoine DJ, Smyth RL. et al. Aminoglycoside-induced nephrotoxicity in children. Pediatr Nephrol 2017; 32: 2015-2025
• 4 Pacheco LF, de Castro CH, Dutra JBR. et al. Oral Treatment with Angiotensin-(1-7) Attenuates the Kidney Injury Induced by Gentamicin in Wistar Rats. Protein Pept Lett 2021; 28: 1425-1433
• 5 Tomşa AM, Răchişan AL, Pandrea SL. et al. Accelerated lipid peroxidation in a rat model of gentamicin nephrotoxicity. Exp Ther Med 2021; 22: 1218
• 6 Perazella MA. Drug-induced acute kidney injury: Diverse mechanisms of tubular injury. Curr Opin Crit Care 2019; 25: 550-557
• 7 Jospe-Kaufman M, Siomin L, Fridman M. The relationship between the structure and toxicity of aminoglycoside antibiotics. Bioorg Med Chem Lett 2020; 30: 127218
• 8 Huang X, Liu Y-X, Lao J-H. et al. The incidence of acute kidney injury in hospitalized patients receiving aminoglycoside antibiotics: A retrospective study. Eur Rev Med Pharmacol Sci 2022; 26: 3718-3725
• 9 Zappitelli M, Moffett BS, Hyder A. et al. Acute kidney injury in non-critically ill children treated with aminoglycoside antibiotics in a tertiary healthcare centre: A retrospective cohort study. Nephrol Dial Transplant 2011; 26: 144-150
• 10 Zorov DB. Amelioration of aminoglycoside nephrotoxicity requires protection of renal mitochondria. Kidney International 2010; 77: 841-843
• 11 Balakumar P, Rohilla A, Thangathirupathi A. Gentamicin-induced nephrotoxicity: Do we have a promising therapeutic approach to blunt it?. Pharmacological Research 2010; 62: 179-186
• 12 Venkatachalam MA, Weinberg JM, Kriz W. et al. Failed Tubule Recovery, AKI-CKD Transition, and Kidney Disease Progression. J Am Soc Nephrol 2015; 26: 1765-1776
• 13 Ferenbach DA, Bonventre JV. Mechanisms of maladaptive repair after AKI leading to accelerated kidney ageing and CKD. Nat Rev Nephrol 2015; 11: 264-276
• 14 Sharma N, Anders H-J, Gaikwad AB. Fiend and friend in the renin angiotensin system: An insight on acute kidney injury. Biomed Pharmacother 2019; 110: 764-774
• 15 Estrela GR, Wasinski F, Almeida DC. et al. Kinin B1 receptor deficiency attenuates cisplatin-induced acute kidney injury by modulating immune cell migration. J Mol Med (Berl) 2014; 92: 399-409
• 16 Estrela GR, Wasinski F, Bacurau RF. et al. Kinin B2 receptor deletion and blockage ameliorates cisplatin-induced acute renal injury. Int Immunopharmacol 2014; 22: 115-119
• 17 Silva LS, Peruchetti DB, Silva-Aguiar RP. et al. The angiotensin II/AT1 receptor pathway mediates malaria-induced acute kidney injury. PLoS One 2018; 13: e0203836
• 18 Ali BH, Bashir AA. Serum angiotensin-converting enzyme activity in rats with gentamicin-induced nephrotoxicity. Nephron 1993; 64: 477-478
• 19 Heeba GH. Angiotensin II receptor blocker, losartan, ameliorates gentamicin-induced oxidative stress and nephrotoxicity in rats. Pharmacology 2011; 87: 232-240
• 20 Bledsoe G, Shen B, Yao Y-Y. et al. Role of tissue kallikrein in prevention and recovery of gentamicin-induced renal injury. Toxicol Sci 2008; 102: 433-443
• 21 Qiu Y, Fernández-García B, Lehmann HI. et al. Exercise sustains the hallmarks of health. J Sport Health Sci 2023; 12: 8-35
• 22 Rahman MM, Kwon H-S, Kim M-J. et al. Melatonin supplementation plus exercise behavior ameliorate insulin resistance, hypertension and fatigue in a rat model of type 2 diabetes mellitus. Biomed Pharmacother 2017; 92: 606-614
• 23 Menezes KK, Nascimento LR, Ada L. et al. Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: A systematic review. J Physiother 2016; 62: 138-144
• 24 Goessler KF, Martins-Pinge MC, da Cunha NV. et al. Direct renin inhibitor therapy and swimming training: Hemodynamic and cardiac effects in hypertensive and normotensive rats. Clin Exp Hypertens 2015; 37: 345-352
• 25 Goessler KF, Martins-Pinge M, Veronez da Cunha N. et al. Treatment with nebivolol combined with physical training promotes improvements in the cardiovascular responses of hypertensive rats. Can J Physiol Pharmacol 2014; 92: 234-242
• 26 Agarwal D, Elks CM, Reed SD. et al. Chronic exercise preserves renal structure and hemodynamics in spontaneously hypertensive rats. Antioxid Redox Signal 2012; 16: 139-152
• 27 de Lima WV, Visona I, Schor N. et al. Preconditioning by aerobic exercise reduces acute ischemic renal injury in rats. Physiol Rep 2019; 7: e14176
• 28 Francescato HDC, Almeida LF, Reis NG. et al. Previous Exercise Effects in Cisplatin-Induced Renal Lesions in Rats. Kidney Blood Press Res 2018; 43: 582-593
• 29 Oliveira CS, Rodrigues AM, Nogueira GB. et al. Moderate aerobic exercise on the recovery phase of gentamicin-induced acute kidney injury in rats. Life Sci 2017; 169: 37-42
• 30 Arazi H, Falahati A, Suzuki K. Moderate Intensity Aerobic Exercise Potential Favorable Effect Against COVID-19: The Role of Renin-Angiotensin System and Immunomodulatory Effects. Front Physiol 2021; 12: 747200
• 31 Frantz EDC, Medeiros RF, Giori IG. et al. Exercise training modulates the hepatic renin-angiotensin system in fructose-fed rats. Exp Physiol 2017; 102: 1208-1220
• 32 Lestari YM, Tarawan VM, Achadiyani A. et al. Exercise intensities modulate ACE2/MasR/eNOS pathway in male Wistar rat’s lung. Physiol Rep 2023; 11: e15803
• 33 Echeverría-Rodríguez O, Gallardo-Ortíz IA, Del Valle-Mondragón L. et al. Angiotensin-(1-7) Participates in Enhanced Skeletal Muscle Insulin Sensitivity After a Bout of Exercise. J Endocr Soc 2020; 4: bvaa007
• 34 Priviero F, De Nucci G, Antunes E. et al. Negative chronotropic response to adenosine receptor stimulation in rat right atria after run training. Clin Exp Pharmacol Physiol 2004; 31: 741-743
• 35 Carvalho JF, Masuda MO, Pompeu FAMS. Method for diagnosis and control of aerobic training in rats based on lactate threshold. Comp Biochem Physiol A Mol Integr Physiol 2005; 140: 409-413
• 36 Brooks GA, White TP. Determination of metabolic and heart rate responses of rats to treadmill exercise. J Appl Physiol Respir Environ Exerc Physiol 1978; 45: 1009-1015
• 37 Haugen HN. The determination of endogenous creatinine in plasma and urine. Scand J Clin Lab Invest 1953; 5: 48-57
• 38 Alp PR, Newsholme EA, Zammit VA. Activities of citrate synthase and NAD+-linked and NADP+-linked isocitrate dehydrogenase in muscle from vertebrates and invertebrates. Biochem J 1976; 154: 689-700
• 39 Vigelsø A, Andersen NB, Dela F. The relationship between skeletal muscle mitochondrial citrate synthase activity and whole body oxygen uptake adaptations in response to exercise training. Int J Physiol Pathophysiol Pharmacol 2014; 6: 84-101
• 40 Barcelos RP, Souza MA, Amaral GP. et al. Caffeine supplementation modulates oxidative stress markers in the liver of trained rats. Life Sci 2014; 96: 40-45
• 41 Cornelissen VA, Buys R, Smart NA. Endurance exercise beneficially affects ambulatory blood pressure: A systematic review and meta-analysis. J Hypertens 2013; 31: 639-648
• 42 Maron BJ, Pelliccia A. The heart of trained athletes: Cardiac remodeling and the risks of sports, including sudden death. Circulation 2006; 114: 1633-1644
• 43 D’Souza A, Bucchi A, Johnsen AB. et al. Exercise training reduces resting heart rate via downregulation of the funny channel HCN4. Nat Commun 2014; 5: 3775
• 44 Wichi RB, De Angelis K, Jones L. et al. A brief review of chronic exercise intervention to prevent autonomic nervous system changes during the aging process. Clinics (Sao Paulo) 2009; 64: 253-258
• 45 Boveris A, Navarro A. Systemic and mitochondrial adaptive responses to moderate exercise in rodents. Free Radic Biol Med 2008; 44: 224-229
• 46 Kawakami S, Yasuno T, Kotoku K. et al. The differences in renal hemodynamic response following high-intensity exercise between younger and older males. Clin Exp Nephrol 2023; 27: 972-980
• 47 Belli T, Macedo DV, de Araújo GG. et al. Mountain Ultramarathon Induces Early Increases of Muscle Damage, Inflammation, and Risk for Acute Renal Injury. Front Physiol 2018; 9: 1368
• 48 Lipman GS, Shea K, Christensen M. et al. Ibuprofen versus placebo effect on acute kidney injury in ultramarathons: A randomised controlled trial. Emerg Med J 2017; 34: 637-642
• 49 Shen H, Feng C, Jin X. et al. Recurrent exercise-induced acute kidney injury by idiopathic renal hypouricemia with a novel mutation in the SLC2A9 gene and literature review. BMC Pediatr 2014; 14: 73
• 50 Shimizu Y, Wakabayashi K, Totsuka A. et al. Exercise-Induced Acute Kidney Injury in a Police Officer with Hereditary Renal Hypouricemia. Case Rep Nephrol Dial 2019; 9: 92-101
• 51 Al Badi A, Al Rasbi S, Alalawi AM. Exercise-Induced Rhabdomyolysis: A Case Report and Literature Review. Cureus 2020; 12: e10037
• 52 Schlader ZJ, Hostler D, Parker MD. et al. The Potential for Renal Injury Elicited by Physical Work in the Heat. Nutrients 2019; 11: 2087
• 53 Húngaro TGR, Freitas-Lima LC, Gregnani MF. et al. Physical Exercise Exacerbates Acute Kidney Injury Induced by LPS via Toll-Like Receptor 4. Front Physiol 2020; 11: 768
• 54 Vallon V. Tubular Transport in Acute Kidney Injury: Relevance for Diagnosis, Prognosis and Intervention. Nephron 2016; 134: 160-166
• 55 George B, Joy MS, Aleksunes LM. Urinary protein biomarkers of kidney injury in patients receiving cisplatin chemotherapy. Exp Biol Med (Maywood) 2018; 243: 272-282
• 56 Abbate M, Zoja C, Remuzzi G. How does proteinuria cause progressive renal damage?. J Am Soc Nephrol 2006; 17: 2974-2984
• 57 Risso MA, Sallustio S, Sueiro V. et al. The Importance of Tubular Function in Chronic Kidney Disease. Int J Nephrol Renovasc Dis 2019; 12: 257-262
• 58 Peruchetti DB, Silva-Filho JL, Silva-Aguiar RP. et al. IL-4 Receptor α Chain Protects the Kidney Against Tubule-Interstitial Injury Induced by Albumin Overload. Front Physiol 2020; 11: 172
• 59 Peruchetti DB, Freitas AC, Pereira VC. et al. PKB is a central molecule in the modulation of Na+-ATPase activity by albumin in renal proximal tubule cells. Arch Biochem Biophys 2019; 674: 108115
• 60 Peruchetti DB, Barahuna-Filho PFR, Silva-Aguiar RP. et al. Megalin-mediated albumin endocytosis in renal proximal tubules is involved in the antiproteinuric effect of angiotensin II type 1 receptor blocker in a subclinical acute kidney injury animal model. Biochim Biophys Acta Gen Subj 2021; 1865: 129950
• 61 Farias RS, Silva-Aguiar RP, Teixeira DE. et al. Inhibition of SGLT2 co-transporter by dapagliflozin ameliorates tubular proteinuria and tubule-interstitial injury at the early stage of diabetic kidney disease. Eur J Pharmacol 2023; 942: 175521
• 62 Nagai J, Sato K, Yumoto R. et al. Megalin/cubilin-mediated uptake of FITC-labeled IgG by OK kidney epithelial cells. Drug Metab Pharmacokinet 2011; 26: 474-485
• 63 Dagil R, O’Shea C, Nykjær A. et al. Gentamicin binds to the megalin receptor as a competitive inhibitor using the common ligand binding motif of complement type repeats: Insight from the nmr structure of the 10th complement type repeat domain alone and in complex with gentamicin. J Biol Chem 2013; 288: 4424-4435
• 64 Balaha MF, Alamer AA, Eisa AA. et al. Shikonin Alleviates Gentamicin-Induced Renal Injury in Rats by Targeting Renal Endocytosis, SIRT1/Nrf2/HO-1, TLR-4/NF-κB/MAPK, and PI3K/Akt Cascades. Antibiotics (Basel) 2023; 12: 826
• 65 Akour AA, Kennedy MJ, Gerk PM. The Role of Megalin in the Transport of Gentamicin Across BeWo Cells, an In Vitro Model of the Human Placenta. AAPS J 2015; 17: 1193-1199
• 66 Cui S, Verroust PJ, Moestrup SK. et al. Megalin/gp330 mediates uptake of albumin in renal proximal tubule. Am J Physiol 1996; 271: F900-F907
• 67 Hori Y, Aoki N, Kuwahara S. et al. Megalin Blockade with Cilastatin Suppresses Drug-Induced Nephrotoxicity. J Am Soc Nephrol 2017; 28: 1783-1791
• 68 Khalifa O, Al-Sahlawi Z, Imtiaz F. et al. Variable expression pattern in Donnai-Barrow syndrome: Report of two novel LRP2 mutations and review of the literature. Eur J Med Genet 2015; 58: 293-299
• 69 Larsen CP, Trivin-Avillach C, Coles P. et al. LDL Receptor-Related Protein 2 (Megalin) as a Target Antigen in Human Kidney Anti-Brush Border Antibody Disease. J Am Soc Nephrol 2018; 29: 644-653
• 70 Al-Kuraishy HM, Al-Gareeb AI, Al-Naimi MS. Renoprotective effect of irbesartan in a rat model of gentamicin-induced nephrotoxicity: Role of oxidative stress. J Lab Physicians 2019; 11: 200-205
• 71 Bae EH, Kim IJ, Joo SY. et al. Renoprotective effects of the direct renin inhibitor aliskiren on gentamicin-induced nephrotoxicity in rats. J Renin Angiotensin Aldosterone Syst 2014; 15: 348-361
• 72 Abdel-Fattah MM, Elgendy ANAM, Mohamed WR. Xanthenone, ACE2 activator, counteracted gentamicin-induced nephrotoxicity in rats: Impact on oxidative stress and ACE2/Ang-(1-7) signaling. Life Sci 2021; 275: 119387
• 73 Alves SAS, Florentino LS, Teixeira DE. et al. Surface megalin expression is a target to the inhibitory effect of bradykinin on the renal albumin endocytosis. Peptides 2021; 146: 170646
• 74 Arazi H, Mohabbat M, Saidie P. et al. Effects of Different Types of Exercise on Kidney Diseases. Sports (Basel) 2022; 10: 42
• 75 Costanti-Nascimento AC, Brelaz-Abreu L, Bragança-Jardim E. et al. Physical exercise as a friend not a foe in acute kidney diseases through immune system modulation. Front Immunol 2023; 14: 1212163

Publikationsverlauf

Eingereicht: 05. Februar 2024

Angenommen: 03. Juni 2024

Artikel online veröffentlicht:
19. Juli 2024