PHARMACOLOGY:

DIURETICS

October 14, 2013 Dr. Gracielle Mia C. Banares

Learning Objectives
Describe the renal tubule system Determine the mechanisms of the renal tubule system Determine the drug action sites of diuretics Determine the mechanisms of action of diuretics

Distal convoluted tubule (DCT) Cortical collecting tubule (CCT) Medullary collecting duct

Review of terms Reabsorption - aka tubular reabsorption Flow of glomerular filtrate from the proximal tubule of the nephron into the peritubular capillaries, or from the urine into the blood Second time that the nutrients are being absorbed into the blood, the first time being from the small intestine into the villi Sodium transport from the lumen into the blood by the Na+/K+ATPase in the basolateral membrane of the epithelial cells

Glomerulus Formation of glomerular filtrate Extremely high water permeability No primary transporters and drug targets at apical membrane No diuretic with major action Proximal convoluted tubule (PCT) Reabsorption of 65% of filtered Na+/ K+/ CA2+, and Mg2+; 85% of NaHCO3 , and nearly 100% of glucose and amino acids Isosmotic reabsorption of water located in the cortex of the kidney Almost all the glucose, bicarbonate, amino acids, and other metabolites are reabsorbed Approximately two-thirds of the Na+ is also reabsorbed Sodium bicarbonate (NaHCO3 ), sodium chloride (NaCl), glucose, amino acids, and other organic solutes are reabsorbed via specific transport systems in the early proximal tubule (proximal convoluted tubule, PCT) Potassium ions (K+) are reabsorbed via the paracellular pathway Water is reabsorbed passively, maintaining the osmolality of proximal tubular fluid at a nearly constant level Sodium bicarbonate reabsorption by the PCT is initiated by the action of a Na+/H+ exchanger (NHE3) located in the luminal membrane of the proximal tubule epithelial cell This transport system allows Na+ to enter the cell from the tubular lumen in exchange for a proton (H+) from inside the cell. As in all portions of the nephron, Na+/K+ ATPase in the basolateral membrane pumps the reabsorbed Na+ into the interstitium so as to maintain a low intracellular Na+ concentration The H+ secreted into the lumen combines with bicarbonate (HCO3) to form H2CO3 (carbonic acid), which is rapidly dehydrated to CO2 and H2O by carbonic anhydrase
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Nephron Basic structural and functional unit of the kidney Antidiuretic Hormone (ADH) aka Arginine Vasopressin (AVP) Two primary functions are to retain water in the body and to constrict blood vessels Vasopressin regulates the bodys retention of water by acting to increase water absorption in the collecting ducts of the kidney nephron

Major Segments of the Nephron and Their Functions Major Segments of the Nephron Glomerulus Proximal convoluted tubule (PCT) Proximal tubule, straight segments Thin descending limb of Henles loop Thick ascending limb of Henles loop (TAL)

Transcribed by: John Harley, Karlo, Joker

Carbon dioxide produced by dehydration of H2CO3 enters the proximal tubule cell by simple diffusion where it is then rehydrated back to H2CO3, facilitated by intracellular carbonic anhydrase After dissociation of H2CO3, the H+ is available for transport by the Na+/H+ exchanger, and the HCO3 is transported out of the cell by a basolateral membrane transporter Bicarbonate reabsorption by the proximal tubule is thus dependent on carbonic anhydrase

cationsincluding magnesium and calciumvia the paracellular pathway Inhibition of salt transport in the TAL by loop diuretics, which reduces the lumen-positive potential, causes an increase in urinary excretion of divalent cations in addition to NaCl

Loop of Henle At the boundary between the inner and outer stripes of the outer medulla, the proximal tubule empties into the thin descending limb of Henle's loop Water is extracted from the descending limb of this loop by osmotic forces found in the hypertonic medullary interstitium As in the proximal tubule, impermeant luminal solutes such as mannitol oppose this water extraction The thin ascending limb is relatively waterimpermeable. Thick ascending limb (TAL) of the loop of Henle Actively reabsorbs NaCl from the lumen (about 25% of the filtered sodium), but unlike the proximal tubule and the thin descending limb of Henle's loop, it is nearly impermeable to water Salt reabsorption in the TAL dilutes the tubular fluid, and it is called a diluting segment Medullary portions of the TAL contribute to medullary hypertonicity also play an important role in concentration of urine by the collecting duct Na+/K+/2Cl cotransporter (called NKCC2 or NK2CL) NaCl transport system in the luminal membrane of the TAL Selectively blocked by diuretic agents known as "loop" diuretics Electrically neutral (two cations and two anions are cotransported), the action of the transporter contributes to excess K+ accumulation within the cell Na+/K+/2Cl cotransporter (called NKCC2 or NK2CL) Back diffusion of this K+ into the tubular lumen causes a lumen-positive electrical potential that provides the driving force for reabsorption of
John Harley, Karlo, Joker

Distal Convoluted Tubule (DCT) About 10% of the filtered NaCl is reabsorbed in the distal convoluted tubule (DCT) Like the TAL of Henle's loop, this segment is relatively impermeable to water and NaCl reabsorption further dilutes the tubular fluid Na+ and Cl cotransporter (NCC) The mechanism of NaCl transport in the DCT electrically neutral thiazidesensitive Distal Convoluted Tubule (DCT) Because K+ does not recycle across the apical membrane of the DCT as it does in the TAL, there is no lumen-positive potential in this segment, and Ca2+ and Mg2+ are not driven out of the tubular lumen by electrical forces Instead, Ca2+ is actively reabsorbed by the DCT epithelial cell via an apical Ca2+ channel and basolateral Na+/Ca2+ exchanger this process is regulated by parathyroid hormone Cortical Collecting Tubule (CCT) Responsible for only 25% of NaCl reabsorption by the kidney Important role in renal physiology and in diuretic action As the final site of NaCl reabsorption, the collecting tubule is responsible for tight regulation of body fluid volume and for determining the final Na+ concentration of the urine A site at which mineralocorticoids exert a significant influence Most important site of K+ secretion by the kidney and the site at which virtually all diuretic-induced changes in K+ balance occur Principal cells are the major sites of Na+, K+, and water transport Intercalated cells are the primary sites of H+ secretion Unlike cells in other nephron segments, the principal cells do not contain cotransport

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systems for Na+ and other ions in their apical membranes Principal cell membranes exhibit separate ion channels for Na+ and K+ These channels exclude anions, transport of Na+ or K+ leads to a net movement of charge across the membrane Because Na+ entry into the principal cell predominates over K+ secretion, a 1050 mV lumen-negative electrical potential develops Na+ that enters the principal cell from the tubular fluid is then transported back to the blood via the basolateral Na+/K+ ATPase The 1050 mV lumen-negative electrical potential drives the transport of Cl back to the blood via the paracellular pathway and draws K+ out of cells through the apical membrane K+ channel Diuretics that act upstream of the CCT increase Na+ delivery and enhance K+ secretion If the Na+ is delivered with an anion that cannot be reabsorbed as readily as Cl (eg, HCO3), the lumen-negative potential is increased, and K+ secretion is enhanced This mechanism, combined with enhanced aldosterone secretion due to volume depletion, is the basis for most diuretic-induced K+ wasting Aldosterone Regulates reabsorption of Na+ via the epithelial Na channel (ENaC) and its coupled secretion of K+ This steroid hormone, through its actions on gene transcription, increases the activity of both apical membrane channels and the basolateral Na+/K+ ATPase This leads to an increase in the transepithelial electrical potential and a dramatic increase in both Na+ reabsorption and K+ secretion

The collecting tubule is also the site at which the final urine concentration is determined Antidiuretic hormone (ADH, also called vasopressin, AVP) Controls the permeability of this segment to water by regulating the insertion of preformed water channels (aquaporin-2, AQP2) into the apical membrane via a G protein-coupled, cAMP-mediated process In the absence of ADH, the collecting tubule (and duct) is impermeable to water, and dilute urine is produced ADH markedly increases water permeability, and this leads to the formation of a more concentrated final urine ADH also stimulates the insertion of urea transporter UT1 molecules into the apical membranes of medullary collecting tubule cells

BASIC PHARMACOLOGY OF DIURETIC AGENTS Carbonic Anhydrase Inhibitors

Carbonic Anhydrase predominant location is the luminal membrane of the PCT, catalyzes the dehydration of H2CO3 By blocking carbonic anhydrase inhibitors block NaHCO3 reabsorption and cause diuresis Acetazolamide Prototypical carbonic anhydrase inhibitor

*** Ion transport pathways across the luminal and basolateral membranes of collecting tubule and collecting duct cells. Inward diffusion of Na+ via the epithelial sodium channel (ENaC) leaves a lumennegative potential, which drives reabsorption of Cl and efflux of K+. (R, aldosterone receptor.) *** Cortical Collecting Tubule (CCT)

Pharmacokinetics Well absorbed after oral administration An increase in urine pH from the HCO3 diuresis is apparent within 30 minutes, is maximal at 2 hours, and persists for 12 hours after a single dose Excretion of the drug is by secretion in the proximal tubule S2 segment Dosing must be reduced in renal insufficiency

Pharmacodynamics Inhibition of carbonic anhydrase activity profoundly depresses HCO3 reabsorption in the PCT

John Harley, Karlo, Joker

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Carbonic anhydrase inhibition causes significant HCO3 losses and hyperchloremic metabolic acidosis Diuretic efficacy of acetazolamide decreases significantly with use over several days

Clinical Indications GLAUCOMA Reduction of aqueous humor formation by carbonic anhydrase inhibitors decreases the intraocular pressure MOST common indication for use of carbonic anhydrase inhibitors Dorzolamide, Brinzolamide: topically active reduce intraocular pressure without producing detectable plasma levels diuretic and systemic metabolic effects are eliminated for the topical agents URINARY ALKALINIZATION Uric acid, cystine, and other weak acids are most easily reabsorbed from acidic urine renal excretion of cystine (in cystinuria) and other weak acids can be enhanced by increasing urinary pH with carbonic anhydrase inhibitors In the absence of continuous HCO3 administration, these effects of acetazolamide last only 23 days Prolonged therapy requires HCO3 administration METABOLIC ALKALOSIS Generally treated by correction of abnormalities in total body K+, intravascular volume, or mineralocorticoid levels However, when the alkalosis is due to excessive use of diuretics in patients with severe heart failure, replacement of intravascular volume may be contraindicated In these cases, acetazolamide can be useful in correcting the alkalosis as well as producing a small additional diuresis for correction of volume overload Can also be used to rapidly correct the metabolic alkalosis that may develop in the setting of respiratory acidosis ACUTE MOUNTAIN SICKNESS Weakness, dizziness, insomnia, headache, and nausea can occur in
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mountain travelers who rapidly ascend above 3000 m In more serious cases, rapidly progressing pulmonary or cerebral edema can be life-threatening By decreasing cerebrospinal fluid formation and by decreasing the pH of the cerebrospinal fluid and brain, acetazolamide can increase ventilation and diminish symptoms of mountain sickness Used as adjuvants in the treatment of epilepsy and in some forms of hypokalemic periodic paralysis and to increase urinary phosphate excretion during severe hyperphosphatemia

Toxicity HYPERCHLOREMIC METABOLIC ACIDOSIS Acidosis predictably results from chronic reduction of body HCO3 stores by carbonic anhydrase inhibitors and limits the diuretic efficacy of these drugs to 2 or 3 days Unlike the diuretic effect, acidosis persists as long as the drug is continued RENAL STONES Phosphaturia and Hypercalciuria occur during the bicarbonaturic response to inhibitors of carbonic anhydrase Renal excretion of solubilizing factors (eg, citrate) may also decline with chronic use Calcium salts are relatively insoluble at alkaline pH, which means that the potential for renal stone formation from these salts is enhanced RENAL POTASSIUM WASTING Can occur because the increased Na+ presented to the collecting tubule (with HCO3) is partially reabsorbed, increasing the lumen-negative electrical potential in that segment and enhancing K+ secretion This effect can be counteracted by simultaneous administration of potassium chloride K+ wasting is theoretically a problem with any proximal tubule diuretic that presents increased Na+ to the collecting tubule

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Drowsiness and Paresthesias are common following large doses of acetazolamide Carbonic anhydrase inhibitors may accumulate in patients with renal failure, leading to nervous system toxicity Hypersensitivity reactions (fever, rashes, bone marrow suppression, and interstitial nephritis) may also occur

Contraindications Hyperammonemia and Hepatic encephalopathy in patients with cirrhosis Carbonic anhydrase inhibitorinduced alkalinization of the urine decreases urinary excretion of NH4+ (by converting it to rapidly reabsorbed NH3)

Loop Diuretics
Selectively inhibit NaCl reabsorption in the TAL Because of the large NaCl absorptive capacity of this segment and the fact that the diuretic action of these drugs is not limited by development of acidosis, as is the case with the carbonic anhydrase inhibitors Most efficacious diuretic agents currently available Furosemide, Ethacrynic acid Prototype drugs Ethacrynic acidnot a sulfonamide derivativeis a phenoxyacetic acid derivative containing a ketone and methylene group Bumetanide, Torsemide sulfonamide loop diuretics

Pharmacokinetics Rapidly absorbed Eliminated by the kidney by glomerular filtration and tubular secretion Effect for furosemide is usually 23 hours and that of torsemide is 46 hours Half-life depends on renal function

John Harley, Karlo, Joker

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