The calcineurin inhibitor tacrolimus activates the renal sodium chloride cotransporter to cause hypertension

Ewout J. Hoorn, Stephen B. Walsh, James (Jim) McCormick, Antje Fürstenberg, Chao-Ling Yang, Tom Roeschel, Alexander Paliege, Alexander J. Howie, James Conley, Sebastian Bachmann, Robert J. Unwin, David Ellison

Research output: Contribution to journalArticle

163 Citations (Scopus)

Abstract

Calcineurin inhibitors (CNIs) are immunosuppressive drugs that are used widely to prevent rejection of transplanted organs and to treat autoimmune disease. Hypertension and renal tubule dysfunction, including hyperkalemia, hypercalciuria and acidosis, often complicate their use. These side effects resemble familial hyperkalemic hypertension, a genetic disease characterized by overactivity of the renal sodium chloride cotransporter (NCC) and caused by mutations in genes encoding WNK kinases. We hypothesized that CNIs induce hypertension by stimulating NCC. In wild-type mice, the CNI tacrolimus caused salt-sensitive hypertension and increased the abundance of phosphorylated NCC and the NCC-regulatory kinases WNK3, WNK4 and SPAK. We demonstrated the functional importance of NCC in this response by showing that tacrolimus did not affect blood pressure in NCC-knockout mice, whereas the hypertensive response to tacrolimus was exaggerated in mice overexpressing NCC. Moreover, hydrochlorothiazide, an NCC-blocking drug, reversed tacrolimus-induced hypertension. These observations were extended to humans by showing that kidney transplant recipients treated with tacrolimus had a greater fractional chloride excretion in response to bendroflumethiazide, another NCC-blocking drug, than individuals not treated with tacrolimus; renal NCC abundance was also greater. Together, these findings indicate that tacrolimus-induced chronic hypertension is mediated largely by NCC activation, and suggest that inexpensive and well-tolerated thiazide diuretics may be especially effective in preventing the complications of CNI treatment.

Original languageEnglish (US)
Pages (from-to)1304-1309
Number of pages6
JournalNature Medicine
Volume17
Issue number10
DOIs
StatePublished - Oct 2011

Fingerprint

Sodium Chloride Symporters
Tacrolimus
Hypertension
Kidney
Phosphotransferases
Bendroflumethiazide
Pharmaceutical Preparations
Sodium Chloride Symporter Inhibitors
Hypercalciuria
Transplants
Inborn Genetic Diseases
Hyperkalemia
Gene encoding
Renal Hypertension
Hydrochlorothiazide
Blood pressure
Immunosuppressive Agents
Acidosis
Calcineurin Inhibitors
Knockout Mice

ASJC Scopus subject areas

  • Biochemistry, Genetics and Molecular Biology(all)
  • Medicine(all)

Cite this

The calcineurin inhibitor tacrolimus activates the renal sodium chloride cotransporter to cause hypertension. / Hoorn, Ewout J.; Walsh, Stephen B.; McCormick, James (Jim); Fürstenberg, Antje; Yang, Chao-Ling; Roeschel, Tom; Paliege, Alexander; Howie, Alexander J.; Conley, James; Bachmann, Sebastian; Unwin, Robert J.; Ellison, David.

In: Nature Medicine, Vol. 17, No. 10, 10.2011, p. 1304-1309.

Research output: Contribution to journalArticle

Hoorn, EJ, Walsh, SB, McCormick, JJ, Fürstenberg, A, Yang, C-L, Roeschel, T, Paliege, A, Howie, AJ, Conley, J, Bachmann, S, Unwin, RJ & Ellison, D 2011, 'The calcineurin inhibitor tacrolimus activates the renal sodium chloride cotransporter to cause hypertension', Nature Medicine, vol. 17, no. 10, pp. 1304-1309. https://doi.org/10.1038/nm.2497
Hoorn, Ewout J. ; Walsh, Stephen B. ; McCormick, James (Jim) ; Fürstenberg, Antje ; Yang, Chao-Ling ; Roeschel, Tom ; Paliege, Alexander ; Howie, Alexander J. ; Conley, James ; Bachmann, Sebastian ; Unwin, Robert J. ; Ellison, David. / The calcineurin inhibitor tacrolimus activates the renal sodium chloride cotransporter to cause hypertension. In: Nature Medicine. 2011 ; Vol. 17, No. 10. pp. 1304-1309.
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