Renal

Physiology





Dr Abhay Umranikar

What Are the Functions of the Kidney? (BT_PO 1.65)

Regulation of the volume, composition and pH of body fluids

Excretion of nitrogenous / metabolic waste
Excretion of drugs and toxins
Metabolic and synthetic - Endogenous / Exogenous substances
Endocrine - Synthetic / Target organ
Long term regulation of arterial pressure

Functional Anatomy (BT_PO 1.61)

Renal anatomy has evolved to serve the kidneys functional obligations

The kidneys are paired structures located within the retroperitoneal space
and protected by ribs. Each adult kidney contains around one million
nephrons, and weighs around 150g. The kidneys have a very high blood flow
in relation to their functioning mass (see below). There is abundant
sympathetic innervation to the capsule as well as blood vessels and tubular
structures. Perinephric fat is brown and highly oxidative

Primary renal processes are filtration, secretion, reabsorption and excretion

Other important processes are synthetic, metabolic and endocrine; however

for the purposes of this discussion there are no specific anatomical features
worthy of mention in relation to these functions

Nephrons are the basic functional unit of the kidney. Each consists of a
glomerulus, tubules, and accompaniying vasculature

All glomeruli are located in the cortex. Most are either subcapsular or mid-
cortex, tend to have shorter loops, are accompanied by peri-tubular
capillaries, and are primarily concerned with filtration and reabsorption

Tubules are arranged in a double horse-shoe manner and ultimately empty

into the renal calyces

Renal microvasculature comprises glomerular capillaries, peritubular

capillaries and vasa recta. Capsular blood supply is independent of these

Functional Anatomy (ctd)

Filtration important anatomical features which aid this process are (1) very
high total blood flow / 100g tissue (2) glomeruli located in the cortex (3) vast
majority of blood flow to the cortex (4) specialised structure of glomerular
units (5) juxtaglomerular apparatus. These are discussed further under the
relevant subsections

Secretion and Reabsorption important anatomical features which aid these

processes are (1) portal arrangement of capillary beds (2) sluggish medullary
blood flow (3) juxta-medullary nephrons with long medullary loops for
concentrating urine (4) counter-current arrangement of loops and
accompanying vasa recta. These are discussed further under the relevant
subsections

Of importance, the medulla is highly metabolically active; yet it only receives

~ 10% of total blood flow and is poorly autoregulated. This makes it
particularly vulnerable to hypoperfusion and ischaemia

Relevant renal microanatomy such as mesangial cells and the juxtaglomerular

appartus will be discussed briefly in the subsections presented below

Renal Blood Flow (BT_PO 1.62, 1.68)

20-25% cardiac output for <1% of body mass (90% cortex / 10% medulla).
Cortical functions (filtration, reabsorption) require high plasma flow.
Medullary functions (concentration) require sluggish plasma flow to minimise
solute washout.
Total blood flow is very high for the functional mass and oxygen consumption
of the kidney. This luxury perfusion is required for filtration + reabsorption.
Renal O2 extraction ~ 1-2ml O2 /100ml (myocardium ~10-12 ml O2 /100ml).

Why is the blood flow so high?

The kidneys have an obligatory solute load to excrete per unit time (e.g. per
day). Assuming complete filtration, the actual amount of a waste product
filtered during each pass through the glomerulus will be determined by its
plasma concentration, filterability and the glomerular blood flow. If the
concentration is high, less glomerular flow would be needed to filter a given
amount, and vice versa. Concentrations of waste products and toxins in the
plasma must necessarily be low for normal body function. Therefore, by
definition, only small amounts will be filtered with each pass and the
glomerular flow needs to be much higher than the metabolic requirements of
the kidney to achieve excretion of the daily obligatory solute load

In the kidney, O2 consumption is determined by blood flow; in other organs
O2 consumption determines blood flow
Renal plasma flow = 600ml/min, GFR = 120ml/min - therefore filtration
fraction = 20% (FF = GFR / RPF). This can increase or decrease depending on
circumstances
In cortical nephrons, flow downstream of the efferent arteriole around the
PCT needs to be maintained at a relatively high rate to facilitate reabsorption
of large amounts of filtered water and solutes. Cortical PO2 ~ 50 mmHg.
On the other hand, medullary flow is much lower in order to optimise
countercurrent concentrating mechanisms
Pressure drops are as follows: Afferent arteriole 100 45mmHg, Efferent
arteriole 45 20mmHg, Peri-tubular capillaries 20 5mmHg (renal veins)
Medullary PO2 is ~ 15 mmHg
Renal blood flow is an example of a portal circulation - two capillary beds in
series (glomerular capillaries peri-tubular capillaries)

Renal blood flow is said to be autoregulated between MAP ~ 70-180mmHg
however there is considerable variation between and within mammalian
species. Clearly many humans function quite normally at lower MAPs!

The sympathetic nervous system (SNS) is important in maintaining sufficient
MAP for autoregulatory mechanisms to be effective (i.e. prevents MAP falling
below autoregulatory minimum for that individual)
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Renal Blood Flow (ctd)

Postulated mechanisms for autoregulation of RBF include:
1. Myogenic
2. Tubulo-glomerular feedback (TGF)
3. A third mechanism independent of the first two

All three are intrinsic to the kidney (i.e. seen in denervated and transplanted
kidneys). Autoregulation serves to minimise fluctuations in RBF + GFR
secondary to changes in MAP, and is a local mechanism. It can be modified
or overridden by extrinsic factors such as SNS and the renin-angiotensin-
aldosterone system (RAAS), in response to significant hypotension or
hypovolaemia
Myogenic autoregulation takes 5-10 seconds and may be important in
protecting the kidney against hypertensive injury. Vasoconstriction occurs in
response to peak systolic stretch of the afferent arteriolar smooth muscle. It
accounts 50% of total autoregulation. The final common pathway probably
involves an increase in cytosolic Ca2+ concentration, and multiple possible
mechanisms have been postulated. These include ion channels (Ca2+, Na+,
K+), vasoactive substances such as NO, angiotensin 2 and HETE, and a role for
the shear-sensitive connexion 40 proteins in endothelial gap junctions
TGF results in reduced glomerular blood flow and GFR in response to
increased solute delivery to the juxtaglomerular apparatus. It is primarily
designed to maintain constant GFR rather than RBF per se, although the two
are obviously interrelated. It accounts for approximately 35-50% of total
autoregulation and takes 30-60 sec. It is discussed further in the following
section describing glomerular filtration
The third process takes 30-60 seconds, but its exact mechanism is unclear. It
appears to be independent of NO, and conflicting evidence exists for the role
of A2

These intra-renal mechanisms can interact variably with extrinsic

determinants of RBF, particularly SNS and RAAS, so that the final value for
RBF and GFR depends on the clinical state of the patient

SNS supplies both afferent (AA) and efferent (EA) arterioles (AA > EA but
greater effect on EA), and is activated by a number of stimuli, most notably
by reduced activity of arterial, venous and atrial stretch receptors. In
addition to its effects on the heart, vasculature and adrenal medulla, SNS
stimulation in the kidney results in:

1. Constriction of both arterioles + renin release

2. Decrease in both RBF and GFR (but RBF > GFR)
3. Increased Na+ and water reabsorption (integral with the actions of A2
and aldosterone)
4. The role of dopamine is controversial and not discussed here
4

Renal Blood Flow (ctd)

1. Direct SNS stimulation (renal nerves - 1 receptors although some

sources state 2. The antihypertensive mechanism of -blockers is at
least partially explained by inhibition of these)
2. Decreased stretch of AA smooth muscle due to hypotension (intra-
renal baroreceptor function)
3. Reduced flow / solute transport at macula densa (MD)
4. Locally released PGs

Renin converts angiotensinogen to angiotensin 1
ACE converts angiotensin 1 to angiotensin 2 (A2)
Renin-angiotensin systems exist in many organs
Renin release is inhibited by A2 (negative feedback), SNS tone,
stretch of AA, solute delivery to the macula densa, ADH, K+, Ca2+

Systemically circulating A2 can influence renal blood flow by:

1. Systemic vasoconstriction / MAP
2. Constriction of both EA and AA (EA > AA)
3. Constriction of mesangial cells

This effect of systemically released A2 in response to hypotension /
hypovolaemia is different to the predominantly AA constrictive effect of
locally released A2 as a part of TGF. The overall effect of A2 on RBF is similar
to that of the SNS it can dramatically reduce RBF downstream of EA.

The overall aim is to generate an integrated neuro-humoral response to

hypovolaemia and hypotension in order to (1) maintain a satisfactory (but
reduced) GFR to perform excretory / clearance functions, whilst (2) balancing
filtration / reabsorption to maintain ECF volume / composition.

RBF can be estimated by first estimating RPF via clearance of PAH or

Diodrast, (an iodine contrast). Clearance of these is 80-90% of RPF because
(1) some RPF perfuses non-tubular components of the kidney and (2) not all
PAH in peri-tubular capillaries is secreted into the tubular lumen. RPF can
only be accurately be calculated by catheterising the renal veins and
measuring renal vein [PAH]. This is impractical!!

In any case, RBF = RPF / (1 Haematocrit)

Renin is released from granular cells of the AA in response to:

Glomerular Filtration (BT_PO 1.63, 1.68, 1.69, 1.77)

Glomerular filtration rate ~ 2ml /kg /min

Glomerular filtrate contains minimal amounts of albumin and other plasma
proteins, and is therefore referred to as an ultrafiltrate
In a sense, glomerular filtrate is analogous to interstitial fluid elsewhere in
the body
GFR = NFP x Filtration Coefficient (Kf)
NFP = net filtration pressure and is determined by the balance of efferent
(EA) and afferent (AA) arteriolar resistances (approx 15mmHg)

EA tone by A2 / sympathetic stimulation
AA tone by A2, VP, sympathetic stimulation, by PGs, by ANP

Compare the differences in Starling forces with non-glomerular capillaries (GC):

1. Much higher hydrostatic pressure in GC

AFF
EFF
2. Almost zero oncotic pressure in BC
PGC
~50
~50mmHg
3. Along with a very high Kf, this promotes rapid
PBC
~15
~15mmHg
and continuous ultrafiltration of large volumes of GC
~20
~30mmHg
plasma - a fundamental function of the kidney
BC
~ 0
~0

NFP
10-15
0-5mmHg
Kf is determined by the hydraulic conductivity
and surface area of the filtration barrier, and is ~50x greater than in non-
glomerular capillaries
This filtration barrier consists of fenestrated vascular endothelium, negatively
charged basement membrane and, epithelial podocytes separated by slits
with thin diaphragms (these trap macromolecules)
The combination of pore and slit size, along with the negative charge, allows
free passage of small and / or neutral molecules, but restricts filtration of
very large or negatively charged molecules
For example, albumin and Hb have similar molecular weights (~ 68Kd); yet
negatively charged albumin is almost completely reflected whilst relatively
neutral Hb readily appears in the urine in the setting of intravascular
haemolysis
Mesangial cells are modified smooth muscle cells located between
glomerular capillaries. In addition to a variety of synthetic and metabolic
functions, they can contract and relax in response to a number of stimuli.
Such activity directly influences capillary diameter, flow, surface area, and
ultimately filtration rate
Mesangial cells contract in response to A2 + VP via PIBP (surface area for
filtration) and relax in response to PGs (via cAMP and cGMP). VP acts via V1
receptors. When mesangial cells contract, there is simultaneous synthesis of
dilating PGs; presumably this is a form of local negative feedback.
Proliferation due to inflammation may also restrict available surface area
(e.g. some types of glomerulonephritis)
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Regulation of GFR (TGF)

Increased GFR results in increased solute delivery to the DCT. This is sensed
by Na-K-2Cl contransporters on the luminal surface of macula densa cells and
transduced by locally generated ATP or adenosine. Under the permissive
action of locally released angiotensin 2 (A2) and PGs, this form of purinergic
transduction causes constriction of the afferent arteriole and glomerular
mesangial cells. This in turn results in decreased net filtration pressure +
surface area available for filtration GFR.
Blockade of adenosine A1 receptors altogether abolishes TGF. Blockade of
Na-K-2Cl by loop diuretics uncouples GFR from solute delivery to the macula
densa, and accounts for their potent diuretic and natriuretic effect.
Note that the action of PGs on AA is biphasic and concentration dependent
prostaglandins can augment the actions of both A2 and NO.
Conversely, if GFR falls, locally synthesised PGE2 / I2 dilate the AA and oppose
actions of A2 and SNS to maintain GFR (hence the potentially dangerous
interaction between hypotension, ACEIs / sartans and NSAIDs on medullary
blood flow and oxygen delivery)
GFR is kept fairly constant over a wide range of blood pressures by TGF, as
long as autoregulation of RBF is maintained by SNS
Further falls in MAP, renal blood flow and renal perfusion pressure will
decrease both GFR and RPF. Compensatory mechanisms will initially attempt
to maintain GFR > RPF by selectively constricting EA > AA (SNS, A2). This
small reduction in GFR will still maintain excretory function to prevent
accumulation of toxic waste products; whilst the effects of (1) glomerular-
tubular balance, (2) SNS, (3) RAAS, (4) ADH, (5) reverse pressure natriuresis
and (6) ANP, will recover greater quantities of salt and water to compensate
for hypovolaemia and hypotension
BUT the cost is RPF and medullary hypo-perfusion

If these autoregulatory mechanisms fail altogether, GFR and RPF will decline
in parallel and increase the risk of acute renal failure
Glomerular filtration typically ceases with MAP < 40 45 mmHg

Estimation of GFR

Useful for:
1. Estimating functional renal mass
2. Following progression of renal disease
3. Adjusting doses of drugs cleared by glomerular filtration

If a substance is freely filtered at the glomerulus, is not renally secreted or
reabsorbed, and is not renally metabolised, then the amount filtered equals
amount excreted and its clearance = GFR
Inulin is one such substance, however Inulin needs to be injected, and
measurements cannot be made until steady state plasma concentration is
reached. This limits its clinical utility
7

Inulin clearance = V.Uin / Pin. (V = urine volume, Uin = urinary [Inulin], Pin =
steady state plasma [Inulin])

Creatinine is an endogenous substance produced from muscle
phosphocreatine and its properties approach those of Inulin. At normal GFR,
~ 10% creatinine is secreted by the tubules, however measured plasma [Cr]
also overestimates true plasma [Cr] by ~ 10% and the two errors tend to
cancel. Therefore, in normal subjects creatinine clearance closely equates
Inulin clearance and hence GFR
Theoretically serum [Cr] and GFR should be inversely proportional; in practice
as GFR decreases, the serum [Cr] does not rise proportionally because
increased secretion partially accounts for the reduced filtration
Creatinine is derived from muscle, therefore when using creatinine based
estimations of GFR one needs to take into account the factors influencing
lean muscle mass of the individual concerned; for example diet, gender, age,
race. Formulae exist to correct for this (estimated GFR or eGFR).

Basic tubular functions (BT_PO 1.63)

o Active (primary or secondary, co- or counter-transport); occurs

against electrochemical gradients. ATP dependent
o Passive (osmosis = water, diffusion = solutes) occurring down
electrochemical gradients
o Transcellular (must cross cell membrane x2)
o Paracellular (solvent drag like throwing a stick into a rushing river)

In general, the proximal part of the nephron is engaged in high capacity,

everyday functions, but with relatively low gain in the face of homeostatic
disturbance. Conversely, the distal parts of the nephron are low capacity but
have significant gain in the face of homeostatic disturbance, and can cause
subtle or profound changes to the bodys electrochemical environment.

For example, filtered sodium and water are mostly reabsorbed in the
proximal nephron but it is their aldosterone / ADH dependent reabsorption
distally that dictates the final effect on volume and tonicity of body fluids.
Similarly, large amounts of bicarbonate are filtered and reabsorbed
proximally, but it is the excretion of much smaller (molar) amounts of
titrateable acid and ammonium distally that is the dominant renal
mechanism in compensating acidosis.

Fundamentally, these can be divided into reabsorption or secretion

Synthetic functions are mentioned where relevant to a particular function

Movement of solutes and water may be

Renal acid - base regulation (BT_PO 1.78)

Regulatory mechanisms:

1. Secretion of H+
2. Reabsorption of HCO3-
3. Excretion of titrateable acidity
4. Excretion of NH4+ (Cl-)

These evolve slowly but remain active until pH is restored

H+ Secretion

1. Secondary active (counter)transport with Na+ (major mechanism)
2. Primary active transport: H+ - ATPase
3. Primary active (counter)transport with K+

Bicarbonate Reabsorption

4-5 moles of HCO3- is filtered at the glomerulus
Reabsorption occurs throughout the kidney and is reliant upon H+ secretion
Majority occurs in the PCT

(1) PCT

85-90% filtered HCO3- reabsorbed - high capacity (but low gain)
Basolateral Na+- K+-ATPase actively pumps Na+ into ECF. This creates the
gradient for Na+ to be reabsorbed from the tubule lumen in exchange for
cellular H+ (NHE3 antiporter), by a process of secondary active transport
(majority of H+ secretion)
Smaller amount of H+ secretion occurs via luminal H+ - ATPase
In any case, secreted H+ combines with filtered HCO3- to form H2O + CO2,
which diffuse back into the cell. This is an inherently slow process and
therefore needs to be catalysed by carbonic anhydrase (CAH type IV) at the
brush (luminal) border
As intracellular H+ is secreted into the lumen, further dissociation of cell
water results in formation of H+ and OH-. This new H+ is again available for
exchange with filtered Na+ and combination with filtered HCO3-; thus the
cycle of H+ secretion HCO3- reabsorption continues
As the luminal CO2 diffuses into the cell, it forms HCO3- by combining with the
OH-, and is catalysed by intracellular CAH (type II)
This intracellular HCO3- is cotransported (3:1) with Na+ at the basolateral
membrane. The process is therefore electrogenic and enhances the electrical
gradient for paracellular absorption of filtered cations such as Na+, K+, Ca2+
and Mg2+ from the relatively +ve luminal fluid in the S2 and S3 segments of
the PCT
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PCT / bicarbonate (ctd)

Net result is that the filtered HCO3- ion is now back in the ECF
These processes are further enhanced by intracellular acidosis, which results
in stimulation / activation of Na+- H+ antiporters, NHE3 and Na+-HCO3-
cotransporters
The Na+- H+ antiporter is also stimulated by high circulating levels of A2 this
contributes to the metabolic alkalosis which can accompany hypovolaemia
(contraction alkalosis)
The selective distribution of these transport proteins (basal / luminal etc) is
maintained by intercellular tight junctions i.e. they are trapped where they
are required (fence function)

(2) Loop of Henle

10-15% HCO3- reabsorbed here, similar mechanisms to PCT


(3) DCT + CDs

Capacity is limited (0-5% reabsorbed here), and reabsorption can be
saturated if the filtered HCO3- load is high, resulting in net HCO3- excretion
(e.g. acetazolamide therapy, acclimatisation to altitude, metabolic alkalosis)
But, high gain when below saturation threshold
Not particularly dependent on luminal CAH
H+ secretion into lumen is predominantly via H+-ATPase (primary active
transport, stimulated by aldosterone) and to a lesser extent by H+-K+-ATPase.
Contrast this to PCT, where counter transport with Na+ dominates
HCO3- transport at the basolateral membrane is via exchange with chloride
rather than electrogenic co-transport with sodium
These processes occur in -intercalated cells; -intercalated cells have the
reverse effect

Excretion of titrateable acidity (TA)

Phosphates account for the majority of urinary buffering under normal
conditions. At pH 7.4 (initial filtrate), PO4 exists mainly (80%) as HPO42-. H+
(dissociated from H2O) is secreted into PCT lumen and combines with filtered
HPO42-, to form H2PO4-
HCO3- remaining intracellularly from reaction of OH- and CO2, is
cotransported at the basal membrane with Na+ (reabsorbed in exchange for
H+), as described previously (3:1). This brings the PCT pH down to 6.8 and
50% of the filtered phosphate has now been titrated
In the collecting ducts, further secretion of H+(luminal proton ATPase) can
depress urinary pH to <6, and all the phosphate is now in the di-hydrogen
form H2PO4-

10

Note that other titrateable acids such as creatinine + -hydroxybutyrate only

make meaningful contributions to titrateable acidity when urinary pH < 5.
Rate of excretion of TA is enhanced in the presence of acidosis; for example,
in severe DKA the increased excretion of -hydroxybutyrate can depress
urinary pH to as low as 4.5

Excretion of NH4+ (note, ammonia and ammonium are often referred to
interchangeably unless otherwise specified)

Under physiological conditions, renal ammonium excretion accounts for 50-
70% of net H+ loss (the rest is TA, above). However, in the presence of
metabolic acidosis this can increase to 90% (TA has a physico-chemical limit)
Unlike most urinary solutes, ammonia is not filtered, but actually synthesised
in tubular epithelial cells
The majority is generated in PCT cells from glutamine, however all tubular
segments are capable of ammonia synthesis
The pKa of the ammonia-ammonium system is ~ 9.2; virtually all exists in the
body as NH4+ with only tiny amounts (< 2%) of gaseous NH3
Although NH3 is uncharged, it is still polar and hence not particularly lipid
soluble. Therefore, movement of NH3 is still quite dependent on specific
membrane transporters

Glutamine enters PCT from peritubular capillaries and filtrate
In the PCT cell glutamine undergoes mitochondrial de-amidation
(glutaminase I) followed by de-amination (glutamic dehydrogenase) to form
2NH4+ and 1 -ketoglutarate2- (KG)
The KG is oxidised to 2HCO3- + 4CO2 + H2O: new bicarbonate is formed and
cotransported with Na+ at the basal membrane (3:1)
These enzymatic reactions are enhanced by acute acidosis, potassium
depletion and glucocorticoids. In chronic acidosis, additional synthesis of
basolateral and mitochondrial glutamine transporters also occurs

In the PCT, NH4+ can replace H+ in the Na+-H+ antiporter (NHE3) described
above, particularly in metabolic acidosis as more NH4+ is generated to begin
with. A possible advantage of substituting H+ with NH4+ is (1) new
bicarbonate is formed in the cell and (2) luminal NH4+ can dissociate into H+
and this can be used to reabsorb filtered bicarbonate as previously described
NH4+ can also replace K+ by competing for the same binding site on K+
transporters. These are located throughout the tubular system on the
luminal surface and represent a second important mechanism for NH4+
transport in the PCT

This is also occurs in the Na-K-2Cl transporter in the TAL of the LOH, but its
significance is uncertain. More important in TAL is basal transport of NH4+
(NHE4) into the medullary interstitium

11

In the medullary interstitium small amounts of NH4+ dissociate into gaseous

NH3 and H+ due to a rise in pH compared to the tubule

This NH3 has two fates:
Firstly, it can diffuse back into the descending limb, combine with secreted H+
and be available as NH4+ to be once again secreted back into the interstitium
by the Na+-K+-2Cl- cotransporter i.e. countercurrent recycling to generate a
cortico-medullary NH3 concentration gradient and maintain a relatively
higher medullary interstitial NH3 concentration. This is further enhanced by
acidic filtrate
The second fate for interstitial NH3 is to diffuse down its concentration
gradient into the collecting ducts, where it can combine with secreted H+
(proton ATPase) to re-form NH4+.
Despite a large concentration gradient, this transport is still largely
dependent on membrane transporters rather than simple passive diffusion.
In essence, simultaneous NH3 and H+ secretion into the lumen has to occur
to form luminal NH4+
This NH4+ is trapped in the CDs and excreted in the urine as NH4Cl this
accounts for the majority of urinary ammonium (hydrogen) excretion
Stewarts theory would alternatively explain this compensation as a net loss
of Cl- rather than H+, with decreased dissociation of H2O to H+
Either way, H+ activity in the ECF is reduced and pH increased

Urinary NH4+ can be estimated by the measured cation gap in urine: [Na+]
+[K+] [Cl-]

In summary, each secreted H+ that combines with one molecule of
titrateable acid or ammonia results in the formation of a new bicarbonate
ion, which is added to the ECF for buffering. In turn, one H+ (Cl-) is
permanently removed and there is net H+ loss. Conversely, each secreted H+
that combines with a filtered HCO3-, effectively reabsorbs this HCO3- ion,
which in turn is returned to the ECF for buffering; no new HCO3- is formed,
and there is no net H+ loss

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Sodium + ECF volume regulation (BT_PO 1.70)

Under physiological conditions ECF volume is determined by its sodium

content. Sodium is mostly confined to the ECF and water exists with it in
osmotic equilibrium. That is to say, the sodium content determines the water
volume of the ECF; wherever sodium goes, water will attempt to follow
It stands to reason that sodium balance will heavily influence ECF volume and
therefore plasma volume, cardiac preload, cardiac output and ultimately
mean arterial pressure and tissue O2 delivery
Sodium is freely filtered at the glomerulus and ~99% is reabsorbed: PCT
~70%; LOH ~20-25%; DCT / CDs remainder
Sodium absorption generally occurs iso-osmotically with water throughout
the kidney except in the thick ascending limb of LOH where absorption is
hypertonic (i.e. Na+ absorption > H2O absorption).

Defence of ECF volume is dependent upon voluntary salt and water intake
coupled with involuntary neuro-humoral responses.
These responses are characterised by cooperative coupling of multiple
sensors and effectors, resulting in sympathetic stimulation and activation of
numerous hormone systems
Target organs are the heart, vasculature, adrenals and kidney. The goal is to
maintain ECF volume, MAP and ultimately tissue O2 delivery
Direct sensors of ECF volume change are:
1. Atrial stretch receptors
2. Arterial baroreceptors
3. Intra-renal baroreceptors (AA granular cells)

Relatively small (e.g. 10%) decreases in ECF volume inhibit atrial stretch
receptors. Such decreases can occur with reductions in dietary Na+ intake,
excessive Na+ loss (e.g. sweating), or redistribution of central blood volume
with changes in posture or mild blood loss. This causes SNS activation, whilst
release of ANP and BNP are inhibited. GFR remains unaltered
Moderate reductions in ECF volume additionally result in a mild reduction in
GFR. Solute delivery to the macula densa is reduced due to increased
proximal absorption of NaCl. Baroreceptor unloading causes further SNS
activation and systemic vasoconstriction, but maintains AA calibre via TGF
(not yet overridden). Renin is released into the systemic circulation with
global activation of the RAAS
Further reductions in ECF volume cause significant reductions in MAP and
GFR that result in still further SNS / RAAS activation with ADH release via
baroreceptor unloading, and reverse pressure-natriuresis. There is near
total inhibition of the release of various natriuretic peptides, and TGF is
overridden

13

The effectors of the response to ECF volume change are:

1. Voluntary thirst, salt hunger
2. Integrated neuro-humoral stress responses causing
Catecholamines (SNS, adrenal) CO, SVR, renal actions
RAAS activity + cortisol (permissive for vascular 1 effects)
ADH
Reverse pressure natriuresis
Inhibited natriuretic peptide activity

SNS and A2 tend to divert blood flow from shorter cortical nephrons to
longer juxtamedullary nephrons, resulting in increased salt and water
absorption in multiple segments of the nephron
Stimulation of SNS + catecholamine release is triggered by reduced
baroreceptor stretch and results in restoration of ECF volume + DO2 by:
1. Increased cardiac output, SVR and MAP
2. Increased EA and AA tone (EA > AA) in order to maintain adequate
(but reduced) GFR but RPF
3. RPF is associated with hydrostatic pressure and oncotic
pressure in peritubular capillaries, which aids salt and water
reabsorption via glomerular-tubular feedback
4. Increased renin release and RAAS activation
5. Increased ADH release
6. Increased catecholamine release from the adrenal medulla, acting on
(a) AA and EA (EA > AA) and (b) increasing the activity of basolateral
Na+-K+-ATPase causing increased Na+ transport into the interstitium
and therefore increased gradient for luminal Na+ reabsorption

Activation of RAAS is caused by SNS activation via renal 1 (? 2) receptors,
and decreased AA stretch. This results in renin release and increased A2,
which acts on:
1.
2.
3.
4.
5.

Systemic + renal arterioles (constriction)

Renal tubules (see below)
Adrenal cortex (aldosterone release)
?ADH release
A3 is has less vascular but same aldosterone effect; A4 is a brain
neuropeptide

14

1. Constriction of both AA and EA (EA > AA) to reduce renal plasma flow
but maintain adequate (but reduced) GFR
2. Increased activity of luminal sodium transporters in the PCT. Reduced
renal plasma flow decreases peri-tubular capillary hydrostatic
pressure and increases oncotic pressure
3. These two effects favour increased sodium reabsorption (GTB, see
below)
4. Via aldosterone (see below)
5. Contrast this to local effects of A2 in TGF as described previously

Aldosterone is a mineralocorticoid synthesised in the zona glomerulosa of

the adrenal cortex. Its release is stimulated by:
1. Hyperkalaemia independent of serum sodium level
2. A2 (K+ and A2 act synergistically via intra- adrenal RAAS)

*These two are the most potent stimuli for aldosterone release, and:

3.
4.
5.
6.

The renal effects of systemically circulating A2 are:

ACTH
Moderate to severe hyponatraemia (independent of K+)
Reduced atrial ( ANP) and arterial stretch (SNS + A2)
Pineal adrenoglomerulotropin (? physiological significance)

Aldosterone acts on the DCT and CDs (see later) to increase Na+ reabsorption
(also gut, salivary and sweat glands). This occurs at the expense of K+ and H+.
Aldosterone also promotes cellular uptake of K+. It is evident that ECF
volume and Na+, K+ and H+ balance are all affected by aldosterone activity
Increased ADH release results in generalised arterio- and veno-constriction,
increased platelet activation, decreased GFR via mesangial cell contraction,
and increased water reabsorption in the collecting ducts
Inhibition of pressure natriuresis this phenomenon is discussed later in the
section on long term control of arterial pressure, and is at least partially A2
dependent
ANP has multiple renal and extra-renal actions. GFR is increased without a
significant increase in renal blood flow, implying constriction of both
arterioles. There is inhibition of sodium reabsorption in the inner medullary
collecting ducts, and possibly inhibition of sodium reabsorption in the PCT via
effects on sodium channel activity. Basal renin release is inhibited, as is A2
and K+ dependent aldosterone release. The response of the CDs to ADH is
likewise diminished. Systemic vasodilation also occurs. Despite this, the
physiological role of ANP remains yet to be firmly established it may have
permissive rather than primary homeostatic actions
15

Tubular processes in sodium reabsorption (BT_PO 1.72, 1.73)

PCT

The energy dependent, basolateral Na+-K+-ATPase provides the gradient for
sodium reabsorption: 33% is transcellular (across the apical and basolateral
membrane) and 66% is via paracellular solvent drag
Water permeability is high (aquaporin 1, luminal surface) and osmotic
equilibrium is rapidly established by trans- and paracellular water
reabsorption into the interstitium
The reabsorption sodium + water in this section is governed by an intrarenal
process called Glomerular-Tubular Balance (GTB)
GTB results in a constant fraction (rather than amount) of filtered sodium and
water being reabsorbed in the PCT. Some proposed explanations for this
phenomenon are:

1. An increase in GFR causes an increase in PCT flow. This reduces the
reabsorption of substances such as HCO3-, glucose and amino acids in
the initial S1 section, in turn resulting in more of these substances
being presented to the S2 and S3 sections. These higher
concentrations result in greater reabsorption of sodium coupled to
these solutes, and in turn, a greater osmotic reabsorption of water
2. Any increase in EA resistance, which leads to increased GFR, also
results in a concomitant reduction in the hydrostatic pressure and
increase in oncotic pressure of blood in the peritubular capillaries
around the PCT. According to Starling forces, increased paracellular
water reabsorption into the capillary will occur, creating solvent drag
for iso-osmotic sodium reabsorption
3. The fraction reabsorbed can itself change, depending on MAP, AA
resistance, and plasma oncotic pressure. For example, MAP, AA
resistance or plasma oncotic pressure (dehydration / hypovolaemia)
will favour increased reabsorption in accordance with Starling forces
this is obviously beneficial. The reverse will happen with MAP, AA
resistance or oncotic pressure
4. Further changes to fractional sodium reabsorption will occur
secondary to the actions of A2 and circulating catecholamines (
reabsorption), or in the setting of sustained arterial hypertension
(pressure natriuresis, reabsorption)

LOH

In the thin ascending segment reabsorptive mechanisms are similar to PCT; in
the thick ascending limb hypertonic reabsorption occurs due to a
combination of Na+-K+-2Cl- cotransport and the impermeability of this
segment to water


16

DCT / CDs

Although the vast majority of filtered sodium and water have already been
reabsorbed, it is the activity of aldosterone which can make significant
adjustments to ECF volume
Aldosterone is responsible for reabsorbing ~2% of filtered sodium BUT this is
a significant amount, considering that 180 l/day of GFR filters 1.5 kg of NaCl!!
Aldosterone competes with cortisol for an intracellular mineralocorticoid
receptor in the principal cells of the DCT and CDs. Cortisol is normally
present at much higher concentrations than aldosterone. These two
hormones have equal affinity for the receptor, but principal cells also contain
the enzyme 11-hydroxysteroid dehydrogenase which inactivates cortisol
If this enzyme is absent or inhibited (e.g. chronic licorice ingestion), a
syndrome of apparent mineralocorticoid excess develops
The hormone-receptor complex acts in the nucleus to stimulate mRNA and
protein synthesis. These aldosterone-induced proteins then act on a
variety of targets including luminal sodium (blocked by amiloride) and
potassium channels, and probably basolateral Na+-K+-ATPase. Sodium
reabsorption into the interstitium stimulates passive paracellular chloride
absorption to maintain electroneutrality.
Aldosterone also stimulates the production of H+- ATPases on the luminal
membrane of the -intercalated cells of the CDs
Not surprisingly, a lack of aldosterone or cortisol results in hyperkalaemia,
acidosis, hyponatraemia, hypovolaemia, hypotension, and shock (if sudden =
Addisonian crisis). Overproduction of aldosterone has the reverse effects
(Conns syndrome if from adenoma); hyperaldosteronism is one the most
common causes of secondary hypertension

17

Potassium regulation (BT_PO 1.72, 1.73)

Only 2% K+ is extracellular, therefore changes in extracellular [K+] can have

marked effects membrane stability (especially cardiac but also peripheral +
central nervous system and non cardiac muscle membranes)
Due to its relatively high membrane permeability, K+ tends to leave the cell
down a huge concentration gradient (overwhelms the opposing electrical
gradient). Therefore it is not surprising that the resting membrane potential
is very close to the Nernst potential for K+
K+ therefore also plays a major role in maintaining intracellular volume
Intracellular enzymes and cell division + growth depend on a realtively
constant intracellular [K+] presumably reflecting cell shape and volume
Finally, K+ is involved in acid-base balance: it is exchanged for H+ across the
cell membrane, and it is substituted by NH4+ in the Na+-K+-2Cl- cotransporter
of the ascending limb
Serum [K+] is determined by the balance between dietary intake, uptake /
release from cells, and excretion by the kidney
Dietary intake in adults is typically 2g (51 mEq) per day
K+ uptake by cells is stimulated by hyperkalaemia, alkalaemia, and hypo-
osmolar states. This uptake is further enhanced by aldosterone, insulin and
catecholamines an absolute or relative lack of these hormones significantly
reduces this buffering capability of potassium
K+ release occurs in the reverse settings and with cell lysis

Renal handling of K+

K+ is filtered at the glomerulus and secreted by tubular cells
At serum [K+] of 4 mmol / l and GFR of 125 ml /min this equals 720 mmol per
day (about 100 medium bananas)
Normally, the kidney excretes approximately 15% of the filtered K+ load of 10
mEq /kg /day
Like Na+, ~66% of filtered K+ is reabsorbed in the PCT
PCT reabsorption occurs by paracellular solvent drag (water reabsorption)
and due to the fact that PCT fluid (in S2 and S3 segments) is positively
charged
Generation of NH4+ is enhanced by hypokalaemia, resulting in net H+ loss at
the expense of K+ loss
In LOH, K+ is secreted into tubular fluid in the descending limb, and
reabsorbed in the ascending limb (Na+-K+-2Cl-), resulting in net reabsorption
of ~25% of the filtered load
In the DCT and CDs, net secretion of K+ occurs under physiological conditions.
This is regulated by aldosterone, pH, and serum [K+]




18

Renal handling of K+ (ctd)

Aldosterone stimulates K+ secretion in principal cells via stimulation of
basolateral Na+-K+-ATPase (increased cellular uptake from ECF) and luminal K+
channels (increased secretion into tubular fluid)
Alkalosis increases tubular fluid pH, thus reducing K+- H+ exchange in
intercalated cells (CDs) favours K+ excretion
Hyperkalaemia increases aldosterone levels, and also provides an increased
gradient for cellular uptake and renal secretion
Increased urine flow maintains low tubular [K+] and increases Na+ delivery,
thereby further enhancing the secretory gradient

19

Regulation of Osmolality and Cell Volume (BT_PO 1.76)

Osmolality, Osmolarity + Tonicity

Osmolality of body fluids is inversely related to body water concentration,

and is regulated by thirst and ADH

Osmolarity = Number of osmotically active particles per litre of solution. It is
predicted by adding up the individual concentrations of all osmotically active
substances, and implies complete dissociation of the dissolved species. In
biological fluids and i.v. solutions, this is overwhelmingly determined by small
ionic substances such as NaCl. Glucose and urea become important
contributors under pathological conditions but do not dissociate like salts

Under physiological conditions, macromolecules such as albumin and

synthetic colloids contribute only 1 mOsm of the total 285-290 mOsm of
plasma. Water volume varies with both temperature and pressure, therefore
osmolarity will be partially determined by these two variables

Osmolality = Number of osmotically active particles per kilogram of solution.

Osmolality is one of the colligative properties of water. The law of
conservation of mass dictates that a given mass of solution, and therefore
osmolality, will be independent of temperature and pressure. Osmolality is
measured e.g. by depression of saturated vapour pressure or freezing point
of the solvent (e.g throwing salt on icy roads. EMLA is another example)

In practice, measured osmolality tends to be slightly less than predicted

osmolarity, possibly because of incomplete dissociation of NaCl

Hartmanns: Predicted = 270-275, measured = 257-260 mOsm/L

Normal Saline: Predicted = 308, measured = 285-290 mOsm/L
4% Albumin (in n.saline): Predicted = 274, measured = 266 mOsm/L

Could the slightly hypo-osmolar 4% albumin have contributed to a poorer
outcome in head-injured patients compared to saline in the SAFE study?
A change in osmolality confined to one body compartment (e.g. ECF) is
capable of causing solvent (water) movement across a semi-permeable
membrane to / from an adjacent compartment (e.g. ICF). This is referred to
as tonicity (effective osmolality)
Changes in ECF tonicity cause changes in cell volume and shape by moving
water into or out of the cell. ECF tonicity can become pathologically or
iatrogenically altered, or be therapeutically manipulated.
Concentrated sodium solutions are both hyper-osmolar and hypertonic as
sodium is confined to the ECF. On the other hand concentrated solutions of
glucose or urea are hyper-osmolar on administration but not hypertonic in
effect
20

Cells in the thick ascending limb and medullary collecting ducts are
particularly exposed to large shifts in interstitial osmolality at the basal
membrane, due to the effects of ADH and urea
However there are a number of mechanisms that buffer rapid changes in cell
volume. For example, along with actions at the luminal membrane, ADH has
a simultaneous effect at the basal membrane of these cells
In the ascending limb ADH stimulates an active uptake of NaCl from the
interstitium that counteracts large transcellular water fluxes (otherwise these
cells would acutely shrink). In the collecting ducts aquaporin 3 and 4 are
inserted into the basal membrane, allowing for rapid transcellular water
movement (otherwise these cells would repeatedly enlarge and shrink)
Another important defence mechanism against exaggerated fluctuations in
cell volume, is the generation and / or uptake of so called osmolytes. This
process is stimulated by increased ionic strength of ICF. These organic
solutes may buffer cell volume by exerting a sustained osmotic effect, and
include sorbitol, inositol and betaine (there are many others!)
ADH is a nonapeptide chemically similar to oxytocin and is secreted into the
blood stream. It is synthesised in the hypothalamus and released from the
posterior pituitary. If the pituitary is resected or damaged, secretion occurs
from the hypothalamus. ADH is metabolised in the liver and kidney;
circulation half life is approximately 20 minutes

Major stimuli for ADH release are:
1.
2.
3.
4.

Increased tonicity of ECF

Reduced atrial stretch
Reduced arterial stretch (mainly carotid sinus)
Miscellaneous stimuli (see below)

Increasing ECF tonicity above 280 mOsm/kg progressively causes dehydration
and conformational change in hypothalamic osmoreceptors, which are cells
in the lamina terminalis. The resultant depolarisation of these cells
stimulates synthesis of ADH in the supra-optic and to a lesser degree, para-
ventricular hypothalamic neurones, along with increased ADH secretion from
the nerve terminals of the posterior pituitary
Atrial stretch receptors sense changes in venous return and preload, which
are assumed by the brain to be surrogates of ECF volume. Volume unloading
of these mechanoreceptors is conveyed to the hypothalamus via vagal
afferents and results in synthesis and secretion of ADH, resulting in
decreased free water clearance. Volume loading has the reverse effect
Arterial baroreceptors send afferent impulses to the paraventricular nuclei
via IX and X. In contrast, supraoptic nuclei are predominangly triggered by
osmotic disturbances. ADH release is not significantly stimulated by normal
fluctuations or minor reductions in MAP (SNS activity takes care of these);
however moderate to severe hypotension causes large amounts of ADH to be
released, with actions on both the kidney and vasculature. ACTH release is
also stimulated by ADH ( cortisol, aldosterone)
21

At physiological concentrations ADH acts predominantly on V2 receptors of

the principal cells of renal collecting ducts; at high concentrations (e.g. severe
shock, therapeutic administration) it acts on both V2 and vascular V1
receptors, as well as causing contraction of glomerular mesangial cells (GFR
+ urine flow). High concentrations also stimulate platelet V1 receptors

The intracellular effect of V2 stimulation is: Stimulation GS protein

adenyl cyclase cAMP protein kinase A cytoplasmic protein
phosphorylation + alteration of cytoskeleton subapical aquaporin vesicles
fuse with apical membrane increased membrane permeability to water.
Any defect in this process can lead to nephrogenic diabetes insipidus (x-
linked and autosomal forms are described)

There are at least 13 known aquaporin subtypes in mammals, of which types
I-VI are found in throughout the kidney on both apical and basolateral
surfaces of tubular cells. Type II is ADH sensitive. Aquaporins do not permit
the passage of charged species and hence allow ion-free water to be
reabsorbed. In the absence of ADH, aquaporins remain within the cell in
subapical vesicles (aggrofores)

The intracellular effect of V1 stimulation is: Stimulation Gq protein
phospholipase C IP3 + DAG protein kinase C + calcium entry into cell
activation of MLCK contraction of vascular smooth muscle, mesangial cells
+ platelets
V1 receptors are further subdivided into V1A (vascular smooth muscle, liver,
platelets, CNS and uterus) and V1B (anterior pituitary + brain stimulating
ACTH release). V2 receptors are also expressed in foetal lung, small cell lung
cancers (SIADH) and liver (releases clotting factors into blood stream)

A rise in tonicity of as little as 1% (3 mOsm/kg) if uncorrected by water
intake, can result in ADH release sufficient to reduce urine flow by and
cause an increase in urine osmolality from 200 to 600 mOsm/kg, until tonicity
is restored

Miscellaneous stimuli - ADH release is stimulated by pain, morphine, hypoxia,

CCK and possibly A2. Its release is inhibited by cold (contributes to cold
diuresis), glucocorticoids, other opioids, and ethanol (ETOH also antagonises
ADH at the kidney). ADH activity is obviously relevant in patients with DI and
SIADH (opposite effects)

Note that ADH is involved in regulation of both osmolality and volume of
body fluids. However, defence of volume takes precedence over regulation
of osmolality and ADH release can continue in the face of hypovolaemia, with
or without the presence of an osmotic trigger. In conditions of chronic
circulating volume depletion (heart failure, cirrhosis, adrenal insufficiency)
attendant hyponatraemia secondary to enhanced ADH levels is common

22

In adults, the range of urine outputs can vary from as little as 0.5 l/day (under
maximal ADH stimulation, urine osmolality ~ 1400 mOsm/kg) to > 12 l/day in
the total absence of ADH activity (e.g. DI, urine osmolality ~ 50 mOsm /kg)
The efficacy of aquaporins is dependent on the presence of (1) hypo-osmolar
urine in the CDs and (2) hyper-osmolar ECF in the medullary interstitium
This gradient is established and maintained by countercurrent multiplication
and exchange mechanisms in the medullary loops of Henle (LOH), and their
accompanying vasa recta. In general, the longer the loop the higher the
osmolality that can be generated at its tip (desert rat up to 6000 mOsm/kg)

Establishment of cortico-medullary concentration gradient (BT_PO 1.64)

This process occurs mainly in juxta-medullary nephrons
The aim is to deliver dilute filtrate to the collecting ducts

It requires 6 steps:

1. Countercurrent flow of filtrate in descending and ascending limbs of
LOH. This allows recycling and concentration of sodium + urea in the
medullary interstitium
2. Differential permeability to water and solute in the descending and
ascending limbs resulting in countercurrent exchange of solute
between these tubular segments
3. Progressive multiplication of single effect in tubular fluid as it
descends into the medulla (see below), promoting the establishment
of a cortico-medullary osmolar gradient
4. Continuous and constant filtrate flow in order to maintain solute
delivery to Na+-K+-2Cl- pumps for active transport into medullary
interstitium if urine flow ceases, the cortico-medullary osmolar
gradient will be abolished, and osmotic equilibrium will be restored
throughout the renal interstitium
5. Countercurrent exchange of solutes between, and slow flow within,
the limbs of vasa recta accompanying the limbs of LOH to minimise
solute washout from the medulla
6. Urea accumulation in medullary interstitium (~50% of osmotic load),
which is critical in generating and maintaining the cortico-medullary
osmolar gradient

The descending limb of LOH is permeable to water (aquaporin 1, ADH
insensitive) but relatively impermeable to solutes such as NaCl
The thick ascending limb of LOH is impermeable to water and has a
frusemide sensitive Na+-K+-2Cl- cotransporter on the luminal membrane that
actively pumps these ions into the tubule cell. NaCl is thus available for
transport into the interstitium
The activity of this cotransporter is determined largely by the Cl- load
presented to it: the higher the load the more active the pump
23

The absorbed Na+ is extruded into the interstitium in exchange for K+ via
basolateral Na+-K+ ATPase and Cl- follows through chloride channels
The K+ is recycled back into tubular fluid via apical K+ channels down its [ ]
gradient. This results in a net positive charge in the tubular fluid
This positive charge in turn drives passive paracellular reabsorption of more
Na+, along with Ca2+ and Mg2+ (this may explain why Mg2+ reabsorption is
impaired in hypokalaemic patients, and why Mg2+ replacement may be
ineffective unless normokalaemia is restored)
The process of hypertonic NaCl accumulation in the medullary interstitium is
called the single effect
An increase in medullary interstitial osmolality causes movement of water
from the descending limb, however this also effectively increases the
concentration of solute available for active transport back out of the thick
ascending limb. At any given level, the osmolality of the descending limb and
interstitium are in equilibrium (descending limb permeable to water); whilst
the osmolality of the ascending limb is ~ 200mOsm/l lower than the
interstitium (the aim being to deliver dilute filtrate to the distal nephron)
Note that the Na+-K+-2Cl- pumps are distributed up and down the length of
the thick ascending limb, therefore the action of the single effect in
countercurrent tubular fluid flow is multiplied by the single effect of pumps
located further and further toward the medullary tip of that loop longer the
loop, greater the effect. This may be one explanation for the term
multiplier. These pumps are particularly prevalent in the juxtamedullary
nephrons. NaCl absorption in the thin (medullary) ascending limb is
additionally thought to have a passive component
The presence of urea further concentrates the medullary interstitium. In the
PCT, more water (60-80%) is absorbed from the glomerular filtrate than urea
(40%). Thus the urea entering the LOH has a concentration 2-3x plasma, and
this favours diffusion of urea into the interstitium
Due to further differential absorption of water, urea is re- concentrated in
the DCT and connecting segments - once again favouring diffusion of urea
into the interstitium
Under the influence of ADH, large amounts of wate are reabsorbed from
medullary CDs. This would tend to dilute the medullary interstitium and
oppose further water reabsorption. However, ADH also facilitates diffusion
of urea out of the CDs by stimulating urea transporters, allowing further urea
accumulation in the interstitium. Urea transporters allow the diffusion of
urea in and out of the tubules and interstitium (several subtypes exist UT-
A1,2,3)) and are located in those parts of the nephron where significant urea
transport occurs (UT-A1 + 3 in CDs, UT-A2 in LOH)

In summary, a cortico-medullary osmolar gradient is established, and filtrate

becomes progressively more dilute as it enters the DCT (as low as 100
mOsm/kg). Relatively dilute filtrate entering the CDs can now be exposed to
a hypertonic interstitium by the actions of ADH (via aquaporin II insertion),
facilitating free water reabsorption from the CDs
24

Glucose handling (BT_PO 1.67)

Renal handling of glucose; physiological consequences of glycosuria (SAQ)

Glucose is freely filtered and normally all the filtered load is reabsorbed in
the PCT by secondary active transport with Na+
The energy for reabsorption is provided by the basolateral Na+-K+-ATPase
which pumps Na+ into the interstitium and creates a gradient for Na+
absorption from tubular fluid

Apical Na+-glucose cotransporters are SGLT-1 and SGLT-2
Basolateral glucose transporters are the high capacity / low affinity GLUT 2

Transport of glucose out of the PCT is saturable, and displays a transport

maximum (Tmax). When the rate of glucose filtration exceeds Tmax, glucose
appears in the urine. The renal threshold for glucose absorption is said to
occur at blood glucose levels in the range of 10-11mmol/l (slightly higher in
males)

As blood glucose rises above threshold, there is an initial non-linear rise in

urinary glucose concentration (splay), after which the rate of rise of urinary
glucose concentration parallels the rate of rise in blood glucose
concentration

Splay is said to occur because (1) nephrons are heterogeneous i.e. will have
different transport maxima and (2) glucose concentration needs to exceed
Tmax before saturation of the cotransport process can occur (typical of
enzymatic processes)

Pathophysiological consequences of glycosuria: consider effects of DKA

versus hyperosmolar-hyperglycaemic non-ketotic coma (HONK), and the
subsequent effects of the osmotic diuresis:
1. Shock 2o to profound hypovolaemia / hypotension with acidosis (keto
in DKA, lactic in both). Further worsened by underlying sepsis /
vomiting / diarrhoea / renal dysfunction
2. Hyperkalaemia (2o to acidosis + insulin lack) despite total body K+
depletion secondary to diuresis. Factitious hyponatraemia 2o to
hyperglycaemia
3. Cardiac depressant and arrhythmogenic effects of pH and
hyperkalaemia; hypokalaemia when pH / BSL corrected
4. Depressed conscious state / coma and hypothermia with further
diuresis and K+ depletion
5. Death if uncorrected!!!

25

Long-term control of arterial pressure

The kidney is the principal long-term regulator of arterial pressure

Baroreceptors, via SNS activity, are vital for detecting and responding to
rapid, short-term changes in arterial pressure. However with sustained
changes in MAP it is thought that progressive desensitisation (unloading)
occurs, and baroreceptor activity tends to drift back to baseline; that is to
say, baroreceptors appear to adapt to the new set pressure and therefore
have finite gain
Conversely the kidney, by a process of pressure natriuresis, is capable of
returning MAP back to the original set point. This set point is different for
different individuals, and is defined by a given level of Na+ excretion for a
given MAP. In essential (primary) hypertension, this set point is moved such
that the same level of Na+ excretion compared to a normotensive subject,
occurs at a higher MAP
In contrast to the baroreceptor / SNS regulation of MAP, this renal
mechanism is described as having infinite gain
Pressure natriuresis is characterised by a modest rise in GFR but a
disproportionate rise in Na+ and H2O excretion. Therefore, the normal
tubular reabsorption of Na+ and water must somehow be impaired after
filtration has taken place. Proposed mechanisms:
1. A rise in medullary blood flow and a fall in renin release
2. A2 and NO, kinin and vasodilator PGE2 activity
3. Increased interstitial hydrostatic pressure in the absence of significant
increase in whole kidney blood flow. This is especially important as it
is a physical phenomenon and not governed by the typical cycle of
gain / feedback / desensitisation seen in neural and humoral
processes (e.g. baroreceptors)
4. Fall in peritubular capillary oncotic pressure
5. Translocation of luminal Na+ transporters and decreased paracellular
Na+ and water reabsorption (?due to disrupted architecture / fence
function)
6. Reduced activity of basolateral Na+-K+-ATPase

All of these processes tend to oppose the reabsorption of sodium and water
after filtration has already occurred, and the elevated excretion of these
entities will continue until a fall in ECF volume returns MAP back to the
original set point
NB there is a growing body of evidence that long term baroreceptor
unloading is not as complete as previously thought, and that there is almost
certainly some role for baroreceptors in the long term regulation of MAP;
however the renal mechanisms are supported by far more published work at
present

26

Endocrine functions (BT_PO 1.66)

Hormone = product of one cell that affects the function of another cell
Classically, targets are said to be distant from the site of production; in the
kidneys locally active agents such as PGs behave as a hormone would, and
can therefore be loosely considered in this context

The kidneys synthesize the following hormones:
1.
2.
3.
4.
5.

EPO
1,25-dihydrocholecalciferol
Renin + local A2 (TGF)
(Arachidonic acid metabolites)
Urodilatin (similar actions to ANP)

The kidneys are targets for:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Catecholamines
Local and circulating A2
ADH
Aldosterone
ANP
PTH
(Ca2+ / PO43- reabsorption)
Vit D
(Ca2+ / PO43- reabsorption)
Calcitonin
(Ca2+ / PO43- reabsorption)
Arachidonic acid metabolites

ANP is a vasodilator released by atrial stretch and opposes the actions of NA
and A2 on the afferent arteriole, increasing net filtration pressure and GFR.
A2 triggered aldosterone release, and aldosterone activity is also
antagonised. These processes all promote natriuresis. The actions of the
other hormones are detailed elsewhere. B type NP is one marker of severity
for long-term congestive heart failure

27

Renal handling of calcium (BT_PO 1.72, 1.73)

Ionised Ca2+ is filtered at the glomerulus

Ca2+ reabsorption is mediated by both active and passive processes

In PCT and LOH, reabsorption of Na+ causes paracellular solvent drag,
facilitating Ca2+ reabsorption down its electrochemical gradient (~ 90%
filtered load). This is enhanced by relatively +ve tubular fluid due to
electrogenic reabsorption of HCO3- (3:1 across the basolateral membrane
with Na+) and recycling of absorbed K+ back into tubular fluid
In the DCT Ca2+ may be (1) exchanged for Na+ via thiazide sensitive Na+
transporters; or (2) be reabsorbed independently of Na+ under the influence
of PTH, calcitonin and Vit D (~ 9% filtered load)
About 1% of filtered Ca2+ is excreted under normal conditions

Ca2+ reabsorption is favoured by:

1.
2.
3.
4.

PTH
Vit D
Alkalosis
Thiazide diuretics

Ca2+ reabsorption is inhibited by:

1.
2.
3.
4.
5.
6.
7.

Calcitonin
GH
Thyroid hormone
Insulin + glucose
Acidosis
Chronic gluco- and mineralo-corticoid therapy
Acetazolamide / frusemide / mannitol

28

GA / Renal Function (BT_PO 1.71)

1. The effect of anaesthesia on renal function

2. The effect of renal (dys)function on anaesthesia management

When considering general anaesthesia and renal (dys)function, one needs to

think about

Anaesthetic effects on renal function:

1.
2.
3.
4.
5.
6.

Effect on MAP, CO, and RBF (+/- aortic clamp)

Disturbance of renal autoregulation by vasodilators
Fasting, pre-existing hypovolaemia, fever, sepsis
Stress response SNS, RAAS, ADH,BSL
Co administration of NSAIDs, ACEIs + sartans, gentamicin, i.v. contrast
Fluoride toxicity (only significant with methoxyflurane, clinical
significance of compound A uncertain)
7. Nephro-protective measures especially with aortic clamping:
dopamine, diuretics, N-acetylcysteine, cooling (none proven; minimise
warm ischaemia time fast surgeon!!). Infra-renal clamping can also
worsen renal function

8. ** KIDNEYS ARE BLOOD PRESSURE DEPENDENT **

Implications of renal dysfunction for anaesthesia management:

1.
2.
3.
4.
5.
6.
7.

Acute or chronic renal failure?

Aetiology of renal failure?
Does the patient make urine?
What is the eGFR?
Comorbidities?
What medications does the patient take?
Consider the effects on pharmacokinetics and dynamics of:

Cause of renal failure e.g. DM / HPT / pre-eclampsia /

rhabdomyolysis / nephrotic syndrome, CCF
Physiological, biochemical + end organ derangements associated
with such precipitating diseases
Physiological derangements from renal failure itself e.g. volume,
BP, K+, platelet + immune function
Impaired elimination of renally cleared drugs
A-V fistulae: i.v. access, BP cuffs; avoid cephalic veins on
contralateral side as these may be required for A-V fistulae in the
future

29

Renal Metabolic Processes

Many of the metabolic processes occurring in the liver also occur in the
kidney. They become particularly important as liver function worsens

1. Oxidation (CP 450 fluoride liberation, MAO A/B)
2. Reduction
3. Hydrolysis (ester, amide)
4. Conjugation
Glucuronidation (propofol, morphine)
Sulfation, Methylation (COMT), Acetylation
Glutathione conjugation

Fluoride Toxicity

The nephrotoxic plasma level of fluoride has historically been described as

being ~ 50 Mol/L. This concern is now also historic. The toxic effect is
classically described as a polyuric, vasopressin-resistant renal failure
Methoxyflurane and sevoflurane anaesthesia can both generate toxic
blood levels, yet significant sevoflurane fluoride toxicity has not been
reported. This may be because methoxyflurane is significantly more
metabolised in the kidney (via 2E1, 2A6 and 3A isoforms of CP450) whereas
sevoflurane is predominantly (93%) metabolised in the liver
In summary, intra-renal fluoride concentrations may be more relevant than
total plasma levels

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Summaries of Important Concepts

Renal Blood Flow - Summary Points

1. Blood flow greatly in excess of metabolic needs
2. Significantly biased toward cortex; portal arrangement
3. Cortex needs high blood flow to effectively filter low [ ] toxins
4. Medulla needs sluggish blood flow to minimize solute washout
5. SNS keeps renal perfusion within autoregulatory range (MAP ?70-180)
6. RBF autoregulated mainly by (1) Myogenic (2) TGF mechanisms; intrinsic to
kidney
7. Note that TGF principally regulates GFR; it does so by manipulating RBF
8. A 3rd mechanism exists but is less well understood
9. All these mechanisms manipulate afferent arteriolar tone via SNS, A2 and PGs
to control inflow of blood into glomerular capillaries
10. Glomerular blood flow also affected by activity of mesangial cells
11. Changes to efferent arteriolar tone influence (1) NFP (2) peritubular blood
flow
12. RBF = RPF / (1 Hct)

Glomerular Filtration - Summary Points

1. GFR = 2ml / kg / min; normally 20% of RPF
2. GFR = NFP x Kf; NFP = 10-15 mmHg
3. Unusual Starling Forces very high capillary hydrostatic pressure (filtration),
minimal interstitial oncotic pressure
4. NFP largely determined by balance between AA and EA calibre
5. Kf determined by surface area, thickness, charge, number of active glomeruli
6. Of these, mesangial cells make the greatest dynamic contribution
7. Mesangial cells contract via A2 / VP; relax via PGs
8. Local regulatory mechanisms are overridden in times of significant
hypovolaemia / hypotension by activity of SNS and RAAS; GFR is kept at the
lower end of the safe range but peritubular flow is dramatically reduced
9. GFR all but ceases when MAP < 40-45 mmHg
10. GFR may be estimated by Inulin or creatinine clearance (eGFR)

Basic Tubular Mechanisms - Summary Points

1. Secretion / Reabsorption
2. Active / Passive transport
3. Transcellular / Paracellular routes
4. Proximal nephron = high capacity / low gain = everyday housekeeping
5. Distal nephron = low capacity / high gain = response to disturbance


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Of importance to anaesthetists, tubular cells are intimately involved in:

1. Acid-Base regulation
2. ECF / Na+ regulation
3. Water / Osmolality regulation
4. K+ regulation
5. Glucose, Ca2+ regulation
6. Renal metabolic processes
Renal Acid-Base Regulation - Summary Points

1. Secretion of H+
2. Reabsorption of HCO3-
3. Excretion of titrateable acidity
4. Excretion of NH4+ (Cl-)

H+ Secretion - Summary Points

1. Secondary active (counter)transport with Na+ (major mechanism)
2. Primary active transport: H+ - ATPase
3. Primary active (counter)transport with K+

Bicarbonate Reabsorption - Summary Points

1. 4-5 moles of HCO3- is filtered at the glomerulus
2. Reabsorption occurs throughout the kidney and is reliant upon H+
secretion
3. Majority (85-90%) occurs in the PCT
4. PCT reabsorption reliant upon processes active in (1) luminal border
CAH (2) the PCT cell - dissociation of cell water and (3) basolateral
membrane electrogenic cotransport with sodium [3:1]
5. Bicarbonate reabsorption results in NO net H+ loss this occurs via
excretion of titrateable acids and ammonium chloride
6. Therefore this process maintains pre-existing ECF buffering by
bicarbonate


Excretion of Titrateable Acids (TA) - Summary Points

1. Under physiologic conditions phosphates account for the majority of TA
2. In the setting of metabolic acidosis, further acid can be titrated down to a
minimum urinary pH of ~ 4.5 an example is ketoacidosis
3. There is net H+ loss




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 Excretion of Ammonium (NH4+) - Summary Points

1. Most exists as NH3 due to high pKa
2. Formed from glutamine which enters PCT from filtrate and blood
3. Synthesis enhanced in the setting of acidosis and stress (usually
concomitant)
4. Ammonium recycled within the loop of Henle
5. Amall amounts of gaseous NH3 is concentrated in the medulla and is
transported into CDs via active and passive mechanisms
6. In the CDs secretion of H+ creates NH4+ and it is ionically trapped,
combined with Cl- and excreted
7. Net loss of H+ or Cl- results in increased pH

Sodium / ECF Regulation - Summary Points

1. There is a subtle difference between sodium content and concentration!!
2. Sodium is confined to ECF and is a strong ion. Therefore the amount of
sodium in ECF will determine the amount of water in ECF i.e. ECF volume.
ECF volume is in equilibrium with plasma volume and hence cardiac preload.
As such, it is a key determinant of CO, BP and tissue oxygenation
3. On the other hand, sodium concentration (osmolality and tonicity of ECF) is
inversely proportional to ECF water concentration under normal conditions.
Factors that affect water concentration (thirst, ADH) will directly influence
sodium concentration. Because water equilibrates freely across the cell
membrane, ECF sodium concentration is actually a reflection of total body
water volume (ICF and ECF)
4. Most sodium is reabsorbed in the PCT and LOH by active transcellular and
passive paracellular transport. Mainly isotonic except thick limb LOH
5. In general, potassium is transported in the opposite direction to sodium
6. ECF volume change is sensed by low and high pressure receptors in the CVS
7. The rectifying effector responses involve activation of SNS, RAAS, ADH and
reverse pressure natriuresis; and suppression of ANP / BNP
8. Aldosterone acts on the DCT and proximal CDs to make final adjustments to
ECF volume
9. Aldosterone release is principally stimulated by A2, hyperkalaemia + ACTH

Renal Potassium Regulation - Summary Points

1. The kidney overwhelmingly dominates potassium removal from the body;
uncorrected acute renal failure = death form hyperkalaemia
2. About 700 mmol of potassium is filtered daily; 85% reabsorbed
3. Most reabsorption in the PCT via solvent drag and electrical gradient
4. Renal potassium excretion is influenced by ECF [K+], aldosterone driven
sodium reabsorption, rate of filtrate (urine) flow and pH changes

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Renal Regulation of Osmolality and Body Water - Summary Points

1. Osmolality is inversely proportional to the water concentration of body fluids
2. Osmolality is controlled by regulating water flux rather than solute flux
3. In response to osmotic disturbance, water flux is principally controlled by
thirst and ADH
4. Most of the filtered water is isotonically recovered in PCT and LOH (except
thick limb); therefore osmotic disturbance can only be corrected distally by
the action of ADH on V2 receptors in the medullary collecting ducts
5. For effective water reabsorption, dilute filtrate in the CDs must be exposed to
hypertonic medullary interstitium

6. Six key components are required to generate the corticomedullary gradient:
1. Countercurrent flow of filtrate in LOH
2. Differential permeability to water + solute in the limbs of LOH
3. Descending multiplication of single effect along limbs of LOH
4. Continuous and stable filtrate flow
5. Slow countercurrent flow in the vasa recta
6. Urea accumulation in the medullary interstitium (critical)

7. The renal actions of ADH include those on mesangial cells, urea transport and
medullary CDs. Aquaporins exist in CD cells, but only fuse with the luminal
membrane under the action of ADH
8. Daily urine output can be 0.5 12 l/day depending on level of ADH activity
9. ADH can be released by non-osmotic triggers, chiefly stress and particularly
hypovolaemia / hypotension. Under these conditions, release continues
even if body fluids are hypotonic volume overrides content!

Renal Glucose Handling - Summary Points

1. Normally all filtered glucose is reabsorbed in the PCT with sodium
2. Tubular Tmax is exceeded around BSLs > 11mmol /l
3. Dedicated enzymatic transporters are required at the apical and basal
membrane
4. These are saturable and saturation occurs initially in a non-linear manner
(splay)
5. Glycosuria results in diuresis; this affects the reabsorption of sodium,
potassium and water. Therefore hypovolaemia, hypokalaemia and
hyponatraemia may all occur
6. Severe acute hyperglycaemia may lead to life-threatening ketoacidosis and or
HONK




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Long Term Control of MAP - Summary Points

1. The kidney is the principal long-term regulator of arterial pressure;
baroreceptors make a modest contribution at best
2. A set point is thought to exist for a given individual which balances a given
daily sodium excretion with arterial pressure. If this set point is disturbed by
an increase or decrease in arterial pressure, continuous stimulation or
inhibition of pressure natriuresis occurs until the set point is restored
3. This predominantly physical phenomenon therefore has infinite gain
4. No single mechanism explains pressure natriuresis, but probably involves
interactions between medullary blood flow + interstitial hydrostatic pressure
and the actions of A2, NO, PGs and kinins
5. The key point is that in the setting of elevated MAP, a modest rise in
medullary blood flow leads to a disproportionate excretion of sodium until
set-point is restored
6. Unsurprisingly, essential hypertension (particularly resistant hypertension)
probably has as its basis, some fundamental disturbance of this process
Suggested Approach to a hormone question

Brief introduction including structure and important functions
Synthesis where relevant
Storage where relevant
Release where relevant
Transport in blood where relevant
Target organ(s)
Mechanism of action
Clinical response(s)
Regulation of activity (feedback)
Metabolism where relevant
Consequences of increased / decreased activity (hint: go here first if youre
struggling for an answer in the exam)
Use this as a template for (1) important anterior and posterior pituitary
hormones, (2) hormones secreted by the thyroid and parathyroid glands,
(3) pancreatic hormones, (4) cortisol, aldosterone and adrenaline, and
although technically not hormones, (5) renin and angiotensin 2, (6)
prostaglandins E and I2

Suggested Approach to an electrolyte question

Brief introduction including charge, valency and important functions
Normal concentrations in ECF v ICF
Detailed explanation of each important function from introduction
Regulation of normal concentrations
Consequences of increased / decreased concentrations (hint: go here first if
youre struggling for an answer in the exam)
Use this as a template for Na+, K+, Ca2+, Mg2+ (?Cl-)
35

References / Bibliography

Vanders Renal Physiology 7th Edition
Weiner, D. Am J Physiology, Jan 2011; 300(1): F11-F23
Hye-Young Kim, Electrolyte Blood Press 7:9-13, 2009
http://www.acbrown.com/kidney/MarioOutline/mario.htm
http://bentollenaar.com/_MM_Book/Ch.31.htm#ch31
Several slide images from www.studyblue.com

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Appendix 1

Counter-current multiplication in Loop of Henle

Osmotic gradient in the medulla is useful in producing concentrated urine. The osmolarity gradually
increases from 300 mOsm/L in the outer medulla to about 1200 mOsm/L in the inner medulla. How is
this gradient established?
Steps Involved in Causing Hyperosmotic Renal Medullary Interstitium
Step-1

First, assume that the loop of Henle is filled with fluid with a concentration of 300 mOsm/L, the same
as that leaving the proximal tubule

Step-2

The active pump of the thick ascending limb on the loop of Henle is turned on, reducing the
concentration inside the tubule and raising the interstitial concentration; this pump establishes a 200-
mOsm/L concentration gradient between the tubular fluid and the interstitial fluid

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Step-3

The tubular fluid in the descending limb of the loop of Henle and the interstitial fluid quickly reach
osmotic equilibrium because of osmosis of water out of the descending limb. The interstitial
osmolarity is maintained at 400 mOsm/L because of continued transport of ions out of the thick
ascending loop of Henle

Step-4

Additional flow of fluid into the loop of Henle from the proximal tubule causes the hyperosmotic fluid
previously formed in the descending limb to flow into the ascending limb

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Step-5

Once this fluid is in the ascending limb, additional ions are pumped into the interstitium, with water
remaining behind, until a 200-mOsm/L osmotic gradient is established, with the interstitial fluid
osmolarity rising to 500 mOsm/L

Step-6

Then, once again, the fluid in the descending limb reaches equilibrium with the hyperosmotic
medullary interstitial fluid, and as the hyperosmotic tubular fluid from the descending limb of the
loop of Henle flows into the ascending limb, still more solute is continuously pumped out of the
tubules and deposited into the medullary interstitium

39

Step-7

These steps are repeated over and over, with the net effect of adding more and more solute to the
medulla in excess of water; with sufficient time, this process gradually traps solutes in the medulla
and multiplies the concentration gradient established by the active pumping of ions out of the thick
ascending loop of Henle, eventually raising the interstitial fluid osmolarity to 1200 to 1400 mOsm/L as
shown in step 7. Thus, the repetitive reabsorption of sodium chloride by the thick ascending loop of
Henle and continued inflow of new sodium chloride from the proximal tubule into the loop of Henle is
called the countercurrent multiplier. The sodium chloride reabsorbed from the ascending loop of
Henle keeps adding to the newly arrived sodium chloride, thus multiplying its concentration in the
medullary interstitium

Blood flow must be provided to the renal medulla to supply the metabolic needs of the cells in this
part of the kidney. Special features of the blood flow in vasa recta that contribute to the preservation
of the high solute concentrations

Countercurrent Exchange in the Vasa Recta Preserves Hyperosmolarity of the Renal Medulla

Blood flow must be provided to the renal medulla to supply the metabolic needs of the cells in this
part of the kidney. Without a special medullary blood flow system, the solutes pumped into the renal
medulla by the countercurrent multiplier system would be rapidly dissipated.
Special features of the renal medullary blood flow that contribute to the preservation of the high
solute concentrations:
1. The sluggish blood flow (accounting for less than 5 per cent of the total renal blood flow) is
sufficient to supply the metabolic needs of the tissues but helps to minimize solute loss from the
medullary interstitium.
2. The vasa recta serve as countercurrent exchangers, minimizing washout of solutes from the
medullary interstitium.

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Appendix 2

Counter-current exchange in Vasa Recta

The countercurrent exchange mechanism

As blood descends into the medulla toward the papillae, it becomes progressively more concentrated,
partly by solute entry from the interstitium and partly by loss of water into the interstitium.
By the time the blood reaches the tips of the vasa recta, it has a concentration of about 1200
mOsm/L, the same as that of the medullary interstitium.
As blood ascends back toward the cortex, it becomes progressively less concentrated as solutes
diffuse back out into the medullary interstitium and as water moves into the vasa recta.
* Thus, although there is a large amount of fluid and solute exchange across the vasa recta, there is
little net dilution of the concentration of the interstitial fluid at each level of the renal medulla
because of the U shape of the vasa recta capillaries, which act as countercurrent exchangers. Thus,
the vasa recta do not create the medullary hyperosmolarity, but they do prevent it from being
dissipated

Source for both Appendices:

http://eamcetzoology.worldpress.com

New Post August 10, 2008

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