Dr.

Niranjan Murthy HL Asst Prof of Physiology ESIC-MC & PGIMSR Bangalore

Weight 150gm each Cortex and medulla Unipapillary : Rat, Rabbit Multipapillary : Dog, Man 4-14 pyramids 1.2 million nephrons in each kidney Nephron length 45 to 65mm

 Cortical nephrons 85% Juxtamedullary nephrons 15%

Nephron
Bowmans capsule Proximal tubule Loop of Henle Distal nephron

Filtration barrier: capillary endothelium, basement membrane, epithelium of bowmans capsule Capillary endothelium- numerous fenestrations Glomerular basement membrane(i) Lamina rara interna (ii) Dense lamina densa (iii) Lamina rara externa Epithelial cells- foot processes or podocytes; filtration slit; slit diaphragm

Juxtaglomerular Apparatus

 Juxtaglomerular cells (JG cells) Macula densa Mesangial/Lacis cells

Blood supply
Renal artery, renal vein Portal system Peritubular capillaries, Vasa recta 12 m2 surface area

Nerve supply
Renal nerves Sympathetic- mainly postganglionic efferent Cholinergic via vagus Afferent & efferent arterioles, proximal & distal tubules, JG cells Reno-renal reflex

Urinary tract and Bladder

Methods in renal physiology

1. Clearance methods: Mass of X excreted/unit time= (mass of X in urine/urine volume) x (urine volume/unit time) Mass of X excreted/unit time = Ux.V Mass of X removed from plasma/unit time = (plasma concentration of X) x (volume of plasma cleared of X/unit time) Mass of X removed from plasma/unit time = Px.Cx

 Px.Cx = Ux.V Cx = Ux.V / Px 2. Micropuncture methods: Aspirate fluid from accessible parts of nephron Measure pressures Measure potential difference Microperfusion Microcatheterization 3. Perfusion of microdissected segments 4. Model tissues

Formation of urine

Filtration and Blood flow

Renal blood flow- 1.2 L/min or 1700 L/min 430 mL/100gm/min Renal plasma flow- 650 mL/min or 900 L/day Filtrate- exclude only cellular elements Ultrafiltrate- exclude cellular elements and proteins Glomerular filtration rate- 125 mL/min or 180 L/day

Filtration barrier
3 layered Endothelium, basement membrane, epithelium

Size discrimination by filtration barrier

Size as well as electrical charges on substances count

[Filtrate]/[Plasma] ratios of selected substances

Substance
Water Urea Glucose Insulin Myoglobin Egg albumin Hemoglobin Serum albumin

Molecular weight
18 60 180 5000 17000 43500 68000 69000

Effective radius
1.0 1.6 3.6 14.8 19.5 28.5 32.5 35.5

[Filtrate]/[Plasma]
1.0 1.0 1.0 0.98 0.75 0.22 0.03 0.01

*Depends on weight, shape and charge of molecule

 Fenestrae in systemic capillaries 50-100 nm Fenestrae in glomerular capillaries 25 nm; slit diaphragm; charged basement membrane; hydrated & tortuous pores Allows neutral substances 4 nm in diameter

Filtered load
Mass of X filtered/time = [concentration of X in plasma] x [volume of plasma filtered/time] Mass of X filtered/time = Px.GFR Mass of X filtered/time = Px.GFR.Fx for substances bound to proteins

Forces involved in filtration

Starlings forces: GFR = Kf [(PG-PB)-(G-B)] Kf filtration coefficient PG glomerular hydrostatic pressure PB bowmans capsule hydrostatic pressure G glomerular colloid osmotic pressure B bowmans capsule colloid osmotic pressure

Glomerular hydrostatic pressure

Bowmans capsule hydrostatic pressure

10 mm Hg Increases in ureteric obstruction Strictures, calculi

Glomerular capillary oncotic pressure

25 mm Hg Increased in dehydration Decreased in hypoalbuminemia Nephrotic syndrome Bowmans space oncotic pressure????

Filtration coefficient
Kf = GFR/Net filtration pressure 12.5 mL/min/mm Hg Increase in thickness of membrane Reduced surface area Glomerulonephritis Nephrotic syndrome Diabetic nephropathy

 Which of the following would tend to increase GFR? A. An increase in glomerular capillary oncotic pressure B.Vasoconstriction of the afferent arteriole C. An increase in hydraulic pressure in the bowmans capsule D. An increase in the renal blood flow

 Which of the following would be expected to cause a large reduction in GFR? A. A reduction in mean arterial pressure from 100 to 95 mm of Hg B. A reduction in plasma oncotic pressure by one half C. A decrease in sympathetic activity D. Complete urethral obstruction

 The glomerular filtration rate:

A. Is greater than 50% of the plasma flow to the glomeruli B. Falls to approximately 25% of normal when mean arterial pressure changes from 100 to 25 mm of Hg C. Is decreased by a decrease in plasma colloid osmotic pressure D. Increases ipsilateral to a ureteral obstruction E. None of the above statements are true

Autoregulation

 RPF and GFR will be maintained even in the presence of large changes of systemic blood pressure 60-130 mm Hg in humans Myogenic theory: Autoregulation is demonstrated in isolated denervated kidney. It is absent when smooth muscles are paralyzed. Stretch operated Ca2+ channels Juxtaglomerular hypothesis: tubuloglomerular feedback Changes in renin secretion

Possible autoregulatory mechanisms of RBF and GFR

Neural regulation
Rich supply of sympathetic vasoconstrictors Moderate sympathetic stimulation- GFR doesnt decrease as much as RBF Further stimulation- GFR reduction parallels that of RBF Other functions: (i) directly increases Na+ reabsorption (ii) Increases renin secretion

 Sympathetic stimulation of the renal arterioles causing a marked reduction in renal blood flow results in:
A. Increased percent absorption of fluid filtered by the nephron B. Decreased GFR C. Decreased peritubular hydrostatic pressure D. A decreased FF

 Sympathetic stimulation of renal arterioles results in: (i) A greater percentage of filtrate being reabsorbed by the renal tubule (ii) A decreased renal FF (iii) Increased peritubular hydrostatic pressure in the kidney (iv) An increased GFR

Hormonal regulation
Angiotensin II: Vasoconstrictor (predominantly efferent) Modulate GFR and RBF Stimulate aldosterone secretion Prostaglandins: PGE2 is a vasodilator Prostaglandin inhibitors decrease RBF & GFR in patients with impaired perfusion of kidneys

ADH: Decrease RBF & GFR Serotonin: decrease RBF & GFR Dopamine: increase RBF & GFR ANP: increase GFR NO: vasodilator; increase RBF Endothelin: potent vasoconstrictor Bradykinin: stimulates release of NO & PGs Pregnancy: GFR & RBF increase by 50% Protein-rich meal: increase RBF & GFR by 30%

Only 10% of RBF goes to medulla High resistance in vasa recta Importance of reduced blood flow to medulla? Renal O2 extraction is 1.7mL/100mL Changes in renal blood flow are accompanied by parallel changes in O2 consumption with AV O2 difference remaining the same. Change in RBF is generally associated with parallel changes in GFR 75% of O2 is used for active reabsorption

GFR depends on diameters of afferent and efferent arterioles

Glomerulus Afferent arteriole Efferent arteriole

GFR

Glomerular filtrate

GFR

Aff. Art. dilatation

Eff. Art. constriction

Aff. Art. constriction

Eff. Art. dilatation

Prostaglandins, Kinins, Dopamine (low dose), ANP, NO

Angiotensin II (low dose)

Ang II (high dose), Noradrenaline (Symp nerves), Endothelin, ADH, Prost. Blockade)

Angiotensin II blockade

Measurement of GFR
Measured using a substance freely filtered and neither reabsorbed nor secreted INULIN- fructose polymer; MW 5000 Mass of inulin excreted/time = Mass of inulin filtered/time UIn.V = PIn.GFR CIn = UIn.V/ PIn CIn = GFR

Creatinine clearance
Endogenous Organic base Degradation product of creatine phosphate It is mostly filtered and partly secreted (1015%) So, mass of creatinine excreted/time mass of creatinine filtered/time Ucr.V = Pcr.GFR

 Ccr = Ucr.V/ Pcr GFR Ccr GFR GFR obtained by creatinine clearance method is slightly greater than that obtained by inulin method Pcr measured by colorimetric methods is slightly greater than actual because other chromagens are also measured along with true creatinine

 Pcr single plasma sample Ucr 24hrs urine collection Pcr changes little with changes in GFR from 125mL/min to 60 mL/min Pcr is useful for detecting large changes in GFR seen in severe renal dysfunction Pcr is 1.25 mg/dL in males and 1.1 mg/dL

 Cx = Ux.V / Px If inulin concentration in urine is 12.5 mg/ml, urine flow rate is 0.5 ml/min and plasma concentration of inulin is 5 mg/100 ml, calculate the inulin clearance value

Measurement of RPF
Ficks equation RPF = Qx/(PRAX-PRVX) Qx is the rate at which a substance X is consumed by kidneys For the substance which is neither synthesized nor metabolized by kidneys, Qx = Ux.V For the substance not consumed by tissues other than kidneys, PRAX = Px Therefore RPF = Ux.V/(Px-PRVX)

 RPF = Ux.V/(Px-PRVX) For the substance completely removed by the kidneys, RPF = Ux.V/Px = Cx PARA-AMINOHIPPURIC ACID 20% of substance cleared by filtration and remainder secreted. 10-15% of plasma goes to parenchyma. So renal venous plasma is not zero EPAH is extraction ratio of PAH fraction of plasma cleared of PAH in a single passage through kidneys

EPAH = (PPAH-PRVPAH)/PPAH EPAH has a value of 0.85-0.90 CPAH = UPAH.V/PPAH = ERPF ERPF = RPF.EPAH RBF = RPF/(1-Hct)

Filtration Fraction
GFR/RPF : 20% In a healthy individual, what percentage of the ERPF would you expect to pass into the glomerular capsule? (i) Less than 5% (ii) 15% to 20% (iii) 70% to 80% (iv) Greater than 90%

 Which of the following substances have greatest renal clearance? (i) Inulin (ii) Sodium (iii) Urea (iv) Creatinine (v) Glucose

 Determine the excretion rate of glucose given the following data: Urine glucose concentration- 125 mg/100 ml Urine inulin concentration- 56 mg/100 ml Plasma glucose concentration- 90 mg/100 ml Plasma inulin concentration- 1 mg/100 ml Urine flow rate- 2 ml/min (i) 112 mg/min (ii) 98.5 mg/min (iii) 200 mg/min (iv) 2.5 mg/min

 With the following data, calculate the renal filtered load of sodium: GFR 100 ml/min Urine flow rate 2.4 ml/min Urine concentration of inulin 1 mg/ml Plasma concentration of sodium 0.12 mEq/ml (i) 20 ml/min (ii) 100 mg/min (iii) 12 mEq/min (iv) 50 ml/min

 Renal clearance of inulin provides a measure of: (i) Renal blood flow (ii) Cardiac output (iii) Glomerular filtration rate (iv) Renal plasma flow

 Calculate the renal plasma flow of a patient given the data below: Effective renal plasma flow 585 ml/min Uncorrected measured Hct 45% Renal extraction of PAH 0.90 (i) 1064 ml/min (ii) 961 ml/min (iii) 1066 ml/min (iv) 650 ml/min

 During infusion of PAH into a patient, the concentration of PAH in cephalic vein stabilized at 0.02 mg/ml of plasma. At this time, both kidneys together were producing 1ml of urine per minute. The PAH concentration in urine was 16 mg/ml. What was the PAH clearance? What was the ERPF?

 Given the following data, calculate the GFR of this patient: Plasma creatinine 0.8 mg/100 ml Plasma urea 15 mg/ 100 ml 24hr urine volume 1600 ml Urine concentration of urea 130 mg/100 ml Urine conc of creatinine 72 mg /100 ml (i) 181 ml/min (ii) 125 ml/min (iii) 100 ml/min (iv) 130 ml/min (v) 154 ml/min

Tubular Reabsorption
Important for conserving water and essential solutes Mass of X reabsorbed/time = (Mass of X filtered/time) (Mass of X excreted/time) Tx = Px.GFR Ux.V Passive and active reabsorption

Active reabsorption
Transport maximum Tm Glucose, Amino acids, Phosphates, Sulphates

Glucose reabsorption
All the filtered load is reabsorbed unless transport system is saturated Na+-glucose co-transporter TmG transport maximum for glucose Tx = Px.GFR - Ux.V TmG = PG.GFR UG.V UG.V = PG.GFR TmG

 Renal threshold for glucose- critical plasma concentration at which glucosuria occurs.

 TmG for men is 375mg/min and 303 mg/min in females Ideally glucosuria first occurs at a plasma glucose level of 300 mg/dL Splay Actual renal threshold for glucose is 200 mg/dL

 Causes of splay: (i) A finite concentration of glucose must remain in tubular fluid to saturate the transport system. K = [G][R]/[GR] (ii) Nephrogenic heterogeneity

Tubular secretion
Unwanted substances are secreted Mass of X secreted/Time = (Mass of X excreted/Time) (Mass of X filtered/Time) Tx = Ux.V Px.GFR Tm limited

Bidirectional Transport
K+, uric acid Both reabsorption and secretion

Proximal Tubule
Water reabsorption Sodium reabsorption Chloride and Bicarbonate reabsorption Glucose & amino acid reabsorption Reabsorption of peptides & proteins Secretion of organic acids and bases Bidirectional transport of uric acid and urea H+ secretion

Sodium reabsorption
2/3rds of reabsorption in proximal tubule 75% accompanied by Cl25% accompanied by HCO3Load-dependent transport Can be altered by sympathetic stimulation, angiotensin II and 3rd factor effect Mechanisms of Na+ reabsorption: 1. Na+ -solute symport 2. Na+ -H+ antiport 3. Cl- driven Na+ transport

Active transport Na+ -K+ ATPase Na+ -solute symport Na+ -H+ antiport Passive transport Cl- driven Na+ transport

Na+ -solute symport: Coupled with glucose, amino acids, lactate, phosphate Segment 1 Cl- absorption via leaky tight junctions

Na+ -H+ antiport: Na+ reabsorption accompanied by Cl- and HCO3 Carbonic anhydrase Formic acid cycle 50% of Na+ reabsorption in PCT

Cl- driven Na+ transport: Ratio of HCO3-:Cl- is 24:110 mmol/L in glomerular filtrate More HCO3- is reabsorbed in segment 1 Increased Cl- concentration in segments 2 & 3

Relative contributions of various Na+ reabsorptive mechanisms:

Na+ -solute symport 10%

Na+ -H+ antiport

With HCO3With Cl-

20-25% 40-50% 20-30%

Cl- driven Na+ transport

Water reabsorption in Proximal Tubule

Transcellular and paracellular Follows solute reabsorption 2/3rds absorbed in proximal tubule Obligatory reabsorption

Aquaporins
Transmembrane glycoproteins 30kDa Peter Agre 13 types in mammals 1, 2, 4, 5 & 8 are exclusively water channels 3, 7, 9 & 10 are aquaglyceroproteins AQP-2 ADH regulated (facultative) AQP-1 PCT & loop of Henle (obligatory) AQP-3 & AQP-4

Glucose reabsorption
99% of filtered glucose is reabsorbed in proximal tubule Plasma glucose 5 mmol/L or 90 mg/dL SGLT-2 on luminal side GLUT-2 on basolateral membrane

Reabsorption of amino acids

Coupled with sodium Reabsorption of peptides and proteins Small peptides may use carriers Large peptides and proteins use pinocytosis Insulin levels in diseased kidneys*

Secretion of organic acids and bases

Active transport at basolateral side Probenecid- competitive inhibitor of organic acid secretion and reabsorption of uric acid Uric acid- bidirectional transport Urea- 40% reabsorbed by the end of segment 2 and secreted in segment 3

Reabsorption of K+ Secretion of K+ Reabsorption of Ca2+, Mg2+, phosphate Reabsorption of lactate, citrate, water-soluble vitamins Synthesis of ammonia

Loop of Henle
Fluid entering LH is isotonic Fluid leaving LH is transformed into hypotonic solution rich in urea Concentration and dilution of urine Medullary osmotic gradient

Thin descending limb

Highly permeable to water Low permeability to solutes with no active transport mechanism

Thin ascending limb

Impermeable to water Highly permeable to Na+ and Cl(reabsorption) Moderately permeable to urea (secretion)

Thick ascending limb

Impermeable to water Low urea permeability Active reabsorption of Na+ and ClNa+/K+-2Cl- symport NKCC2

 CIC-K channels with -subunit Barttin Defective Barttin causes salt loss and sensoryneural deafness ROMK channels Na+ reabsorption is load-dependent Loop diuretics- Furosemide & Bumetanide

Distal nephron
Includes, DCT, connecting tubule and collecting duct Transforms the tubular fluid to urine Reabsorption of 5-10% Na+, 15% water, reabsorption of urea, secretion of K+ & H+

DCT and connecting tubule

Na+-Cl- symport NCCT Blocked by thiazide diuretics CIC-Kb transporter Na+ reabsorption is load-dependent

 Low water and urea permeability Active Na+ reabsorption

Collecting duct
Conductive Na+ channels (ENaCs) Load dependent Na+ reabsorption Low permeability to ClHigh transepithelial PD (-70 mV) Tight tight junctions ANP and PGs Triamterene and Amiloride Spironolactone- K+ sparing diuretic

Water and urea permeability in collecting duct

ADH dependent V2 receptors AQP2 channels UT-A1, UT-A2, & UT-A3 receptors

Mechanism of concentration of urine

Effect of maximal ADH secretion

Final urine has osmolarity of 1200 mmol/L with urea contributing 600 mmol 0.5% of filtered water is excreted If GFR is 125 mL/min, urine flow rate will be 0.6 mL/min or 0.9 L/day

Absence of ADH
Final urine osmolarity will be 70 mOsmol/L with urea contributing 50 mmol 15% of water is not reabsorbed With a GFR of 125 mL/min, urine flow rate will be 15 mL/min or 26 L/day