a.

In spite of glomerulotubular balance, the percentage of filtrate reabsorbed here is altered by certain
circumstances and mechanisms.
7. NaCl and NaHCO3 (sodium bicarb) constitute ~90% of all the solute in the extracellular fluid and in the glomerular
filtrate.
a. They account for 90% of the body’s osmolality.
b. Of this 90%, ~20% is NaHCO3 and ~80% is NaCl.

Explain how salt and water are reabsorbed across the epithelium of the proximal tubule. Name the principal
transport proteins found in the proximal tubule. Explain how these, combined with transepithelial electrical forces
and tight junction characteristics, underlie its transport properties.
Early Proximal Convoluted Tubule
1. The first half of the PT
2. Most essential solutes are reabsorbed with Na
a. Glucose, amino acids, HCO3-
3. “Highest priority” reabsorptive work- critical metabolic role of glucose and amino acids and critical buffering role of
HCO3- mean it is super important that they get reabsorbed
4. Luminal membrane has a lot of secondary active transporters that couple Na going down its gradient to bring other
solutes into the cell= Cotransporters
5. There is one countertransporter- Na/H+ Exchanger
a. H is brought out of the cell into the lumen while Na goes into the cellà H combines with HCO3- à converts
it to CO2 and H20 that go into the cellà re-converted back to HCO3 and H+ à HCO3- goes into blood and H
can be pumped back into lumen to do it all over again
6. Lumen-Negative potential difference created by Na/Glc and Na/aa cotransporters
a. Transporters bring net positive charge into the cell and leave negative charge in the lumen
b. The other transporters are electroneutral so they don’t contribute
7. On basolateral membrane
a. Na/K pumps push Na out of cell and into blood
b. Sugars, amino acids and metabolic intermediates diffuse through down their gradients
8. By the time you go halfway down the PT
a. 100% of filtered glucose and amino acids are reabsorbed
b. 85% of filtered HCO3- is reabsorbed
c. most of the filtered phosphate, lactate and citrate are reabsorbed
d. Na has been extensively reabsorbed since it’s coupled to everything above

Late Proximal Tubule

1. Fluid entering the Late PT has no glc or amino acids and very little HCO3-
2. It has a high Cl- concentration
a. So it absorbs primarily Na and Cl
 b. High tubular Cl concentration is driving force
3. Two exchange mechanisms
a. Na/H Exchanger
b. Cl/Formate/Anion Exchanger
c. Combined function of these two Exhcangers is to transport NaCl from the lumen into the cell
d. Na is then extruded into the blood by the Na/K ATPase pump and Cl goes into blood by diffusion
4. Paracelluluar mechanism
a. Leaky tight junctions are permeable to small ionsà So Cl diffuses down its concentration gradient
b. This creates a Cl Diffusion Potentialà Makes the lumen positive compared to bloodà Driving force for Na
diffusion

Isosmotic Reabsorption
1. Water transport is coupled to solute transport- driven by osmosis
a. Uses aquaporins
2. Water and solute are tightly coupled so the reabsorbed fluid is isosmotic

Additional Transport Processes

1. Na and Cl reabsorption are also linked to Na/H and Cl/Formate Exchangers working together
a. H and Formate are pushed into the lumen while Na and Cl are brought into the cellà H and Formate
combine in the lumen and makes Formic Acid (highly permeable)à goes into cellà dissociates back to H
and Formateà gets reused
b. Net result is neutral NaCl uptake
2. 50% of urea is reabsorbed passively
3. SECRETES organic anions, organic cations and drugs

Define glomerulotubular balance and explain its importance.

1. Rate of fluid reabsorption by the proximal tubule is usually a constant percentage of the GFR, 65-70% critically
important for normal renal function
2. If GFR increasesà reabsorption in the PT needs to increase and not be dumped on the rest of the nephron
3. Primary Mechanism of GT Balance ni PT
a. ↑ GFRà ↑ delivery of bicarbonate, glucose, amino acidsà ↑ Na and H2O Reabsorption
4. constant fraction (or percentage) is normally maintained at 67% of the filtered load

Describe how peritubular forces can alter glomerulotubular balance and net reabsorption rates across the
proximal tubule.
Capillary forces modulate Proximal GT Balance
1. Hypervolemiaà ↓ oncotic pressure and ↑ hydrostatic pressureà ↓ capillary fluid uptakeà ↓ Reabsorption and ↑
Excretionà Hypervolemia is reversed
2. Hypovolemia has opposite effect
a. Concentrates plasma proteins and decrease venous pressureà increase in oncotic pressure and decrease in
hydrostatic pressureà favor reabsorptionà less salt and water are excretedà extracellular volume is
conserved

List the various factors that affect fluid reabsorption in normal proximal tubules.
Urine Concentration and Dilution (The Rest of the Nephron: Forming Hypo- and Hyperosmotic Urine) AND
H2O Homeostasis Thursday

List the key transport properties of each of the remaining major nephron segments.
Name the principal transporters found in each segment: thick ascending limb, distal tubule, and collecting tubule.
Explain how these, combined with transepithelial electrical forces and tight junction characteristics, underlie the
transport functions of each segment.
State the significance of the presence or absence of glomerulotubular balance in each of these remaining
segments.
List the diuretics described in this lecture, and briefly explain their mechanisms and potential side effects.
Describe how regulation of both of GFR and upstream transport are essential for "setting the stage" for fine-tuning
of reabsorption by the collecting duct.
Describe the mechanisms by which urine is concentrated, including counter-current multiplication, the roles of the
vasa recta, and the actions of ADH.
State the routes and rates of daily water turnover.
Understand why the body tends to lose water relatively faster than solute, and its implications for patient
management.
Characterize the mechanisms and feedback loops whereby water balance is regulated in direct response to
changes in osmolality and circulating volume.
Describe the effects of high solute loads or diminished renal capacity on the body’s ability to regulate its water
balance.

Renal Pharmacology Thursday

Define the autonomic nervous system innervation targets for the kidney.
1. Only sympathetic division of the ANS
a. Renal sympathetic nerves originate from the intermediolateral column of the SC from T9 to T12
b. Nerves carrying fibers that run to or from the kidney are derived from the celiac plexus
c. Postganglionic fibers originate from the celiac plexusà follow the arterial vessels to the kidney
2. NO Parasympathetic

Targets and Effects- Increases is SNA on the kidneyà

1. Juxtoglomerular Granular Cells
a. Effect: Increase in Renin Release
b. β 1 adrenergic receptor mechanisms (Gs)
2. Renal artery and afferent/efferent arterioles
a. Effect: Vasoconstriction
b. α 1 adrenergic receptor mechanisms (Gq)
3. Peritubular Membranes
a. Effect: Transtubular sodium resorption
b. α 1 and α 2 adrenergic receptor mechanisms (Gq and Gi)
c. stimulate Na/H Exchanger in PT cells, Na/K ATPase activity

Atrial Natriuretic Peptide

1. Secreted mainly by the right atrium in response to atrial distensionà maintains Na homeostasis and inhibits
activation of the RAAS
2. Induces natriuretic/diuretic and vasodilatory responses by antagonizing the vasoconstrictive influences if AGII,
endothelin, AVP and α 1 adrenergic input
 3. well-characterized polypeptide contained in specific granules within cardiac atria
4. Increased ECFà ANP releaseà decreases SVR and increase urinary excretion of Naà water follows Na
5. Renal mechanisms are poorly understood
a. When bound to receptors on the principal cells, they counter aldosterone by slowing Na+ reabsorption
b. Also increase GFR and RBF by binding to receptors on the glomerulus

Describe the 4 main processes for drug elimination in the kidney: glomerular filtration, active tubular secretion,
passive tubular reabsorption, ion trapping.
Glomerular Filtration
1. GFR ~ 20% of renal blood flow (free drug enters by diffusion)
a. 80% passes on to peritubular capillaries
2. Glomerular Filtration ~ 130 ml min-1 of plasma filtered
3. Passive Process where drugs and other endogenous substances with MW < ~ 5kD and effective radii < 15Å are filtered
a. < 1% of albumin (molecular weight ~ 69kD, is filtered at the glomerulus
4. GFR Assessment with Inulin
a. Not synthesized or metabolized
b. Filters freely through the glomerular barrier
i. Uncharged, not bound to plasma proteins, freely crosses most capillaries but doesn’t traverse cell
membrane, non-toxic
c. Not reabsorbed or secreted
d. Inulin clearance= 125-130 ml/min in humans
5. If Clrenal depends on filtration, ClRenal = GFR x fu
a. fu= unbound fraction of drug since only the unbound drug filters
6. Protein binding: only free fraction of drug crosses glomerulus
a. Protein + Drugfree « Protein-Drugbound
b. In peritubular capillaries: dissociation of bound drug allows for the free drug to diffuse from capillary;
significant amounts of drug (derived from bound fraction) can diffuse from capillary as equilibrium shifts to
the left

Active Tubular Secretion

1. At proximal tubule
2. Major pathway of elimination for many drugs
3. Anion Transporters (OATs) and Cation Transporters (OCTs)
a. Are expressed in the PT
b. Mediated uptake of predominately small organic cations and anions in the liver and kidney
c. Are saturable and susceptible to competitive inhibition by other organic ions
4. Organic Anion Transporters- OATs
a. P-Aminohippuric Adic (PAH)
i. Used to study renal tubular anion secretion
ii. Cleared by both filtration and secretion- Completely cleared from plasma
iii. Differs from inulin in that the fraction of PAH that bypasses the glomerulus and enters the tubular
cells (via peritubular caps) is completely secreted
iv. PAH clearance is a method used in renal physiology to measure renal plasma flow
5. Organic Cation Transporters- OCTs
a. Examples: amantadine, cimetidine, pindolil, quinidine are all secreted
b. Transportation of toxic organic cations into the kidneys may lead to nephrotoxicity
i. Example: Gentamicin- aminoglycoside antibiotic can cause nephrotoxicity

Passive Tubular Reabsorption/Ion Trapping

1. At DT or Collecting Duct CD- for lipid soluble and unionized drugs
a. Due to loss of H2O in tubule, drug concentration in tubule is higher than drug concentration in bloodà so it
will diffuse down its concentration gradient
 2. Ion trapping- ionized compounds and lipid insoluble drugs remain in the tubule and pass in the urine

Define renal drug clearance.

1. Physiologically, clearance is determined by:

a. Blood Flow Q- to the organ that metabolizes (liver) or eliminates (kidney) the drug
b. Efficiency- of the organ in extracting the drug from the bloodstream
i. Calculated by subtracting the concentration in the blood leaving the extracting organ Cout (Cvein)
from the concentration in the blood entering the organ Cin (Cart)

2. Definition- Hypothetical volume of plasma from which the blood is completely removed per unit time (L/hour,
ml/min, ect.)
a. It is a constant for each particular drug in normal
b. Cl= rate of elimination / plasma drug concentration
c. Can describe either hepatic blood flow, renal blood flow or total body (systemic)
d. Ex: Renal Clearance- volume of plasma containing the amount of drug that is removed by the kidney in unit
time
i. Depends on GFR, tubular reabsorption and tubular secretion

Explain the relevance of drug-protein binding for renal clearance.

Drugs will only go into the tubules if they are not bound to proteins in the plasma
The more drug that is bound to plasma proteins, the less the drug will be filtered or secreted

Describe the role of organic anion and cation transporters for renal drug clearance.
*from above

1. Organic Anion Transporters- OATs

a. P-Aminohippuric Adic (PAH)
i. Used to study renal tubular anion secretion
ii. Cleared by both filtration and secretion- Completely cleared from plasma
iii. Differs from inulin in that the fraction of PAH that bypasses the glomerulus and enters the tubular
cells (via peritubular caps) is completely secreted
 iv. PAH clearance is a method used in renal physiology to measure renal plasma flow
2. Organic Cation Transporters- OCTs
a. Examples: amantadine, cimetidine, pindolil, quinidine are all secreted
b. Transportation of toxic organic cations into the kidneys may lead to nephrotoxicity
i. Example: Gentamicin- aminoglycoside antibiotic can cause nephrotoxicity

Pharmacological Targets to Modulate Renal Function

1. Diuretics- cause natriuresis, to treat volume overload, HTN, liver cirrhosis, nephrotic syndrome, CHF
a. Inhibit specific solute transporters within each segment of the nephron
b. Have inhibitory effects from the luminal side, (except spironolactone)
i. Thiazides by inhibiting the Na+-Cl- cotransporter of the distal tubule
ii. Loop diuretics and the Na+-K+-2Cl- co-transporter of the loop of Henle,
2. Very little diuretic is filtered at the glomerulus
3. Carbonic Anhydrase Inhibitors (CAIs), thiazides and loop diuretics are all highly bound to albumin
4. Consequence of 2 and 3?
a. Secretion by the proximal tubule= main route of urinary excretion
b. Tubular secretion is critical for the action of loop and thiazide diuretics

Identify the target site and uses of carbonic anhydrase inhibitors (Acetazolamide).
1. Act mainly at the proximal convoluted tubule
2. Bicarbonate absorption by the PT is dependent on the activity of carbonic anhydrase (CA).
3. Bicarbonate and H+ come together to form Carbonic Acid in the lumenà CA converts Carbonic Acid to CO2 and H2O in
the lumenà CO2 diffuses into the cells of the PT and is rehydrated back to Carbonic Acid H2CO3 by CAà H2CO3
dissociates to bicarbonate (HCO3-) and H± à HCO3- and H+ get transported out the basolateral side by various
transporters (or the H+ gets reused and pumped out with the Na/H Exchanger again)
4. Inhibiting CA with acetazolamide causes increased urinary loss of sodium bicarbonate Na+ HCO3- (this takes water
along with it) à This interferes with the reabsorption of Na and Clà Basolateral Na/K ATPase maintains low
intracellular Na concentration (necessary for reabsorption of Na) and the PT also facilitates the efflux of Na by the
Na/H Exchanger on the luminal sideà Increased delivery of Na to the collecting duct (because it stays in the lumen
with bicarbonate HCO3-) causes reabsorption of Na (through Na channels) in exchange for increased efflux of Kà Can
cause Hypokalemia
5. “zolamide”= Carbonic Anhydrase Inhibitor
6. Weak diuretic since it acts early in the nephron
a. Can be used as an add-on therapy with loop or thiazide diuretics
b. Most of the fluid loss can be regained later on in the nephron
7. Loss of bicarbonate HCO3- can cause metabolic acidosis
8. Nice video: https://www.youtube.com/watch?v=ueSTQo8041o

Identify the target site and uses of loop diuretics (furosemide).

1. Act at the medullary and cortical Thick Ascending Limbs
2. Cells lining the thick ascending limb of the loop of Henle have Na/K/2Cl Cotransporters- these have high sensitivity to
action of loop diuretics
3. Increase Calcium Loss
 4. This segment also has lumen-positive potential, a high luminal potassium conductance and a peritubular Na/K ATPase
that lowers intracellular Naà steepens gradient for Na entry on the luminal side
5. The Na and Cl concentration gradients between the lumen and inside the cell favor net reabsorption of Na and Cl by
the electroneutral Na/K/2Cl Co Transporter
6. Loop diuretics compete for the Cl binding site of theseà inhibits its functionà increases delivery of ions and fluid to
the distal tubuleà reduces osmolarity gradient from cortex to outer medulla
7. Increased Na delivery to the DT also enhances K secretion into the urine via Na/K Exchanger and another mechanism
(not well known, flow-dependent mechanism that enhances K secretion)
8. Strong diuretics = High Ceiling Diuretics
9. Urinary output usually dose-dependent
10. Used for: edematous states (CHF, Pulmonary Edema), Acute Hypercalcemia
11. Side Effects: Hypokalemic Metabolic Alkalosis, Ototoxicity, Hyperuricemia (can lead to gout)
12. Video: https://www.youtube.com/watch?v=22DTm-JVdWo

Identify the target site and uses of thiazide diuretics (hydrochlorothiazide).

1. Inhibit solute transport in the Distal Convoluted Tubule
2. Secreted into the proximal tubule by an organic secretory mechanism (compete for the same process that uric acid is
secreted)
3. Act to increase excretion of Na and Cl (and Hydrogen ions)
4. Increase Calcium Reabsorption
5. Compete for the Cl binding site on the Na/Cl Cotransporter that is only in the distal convoluted tubuleà lowers
intracellular Naà Increased action of Na/Ca Exchanger on the basolateral side (to bring Na back into the cell, will also
take Ca out of the cell) à Facilitates the diffusion of calcium through Ca ion channels on the luminal side into the
cellà Better Calcium Reabsorption
6. Inhibition of Na transport in this segment increases the amount of Na delivery to the collecting ductà enhanced
reabsorption of Na through channels in the CDà enhanced K efflux into CDà Can cause Hypokalemia
7. Antihypertensive mechanism is poorly understood but one hypothesis is that is causes smooth muscle relaxationà
vasodilation
8. Used for: HTN, Heart Failure, Kidney Stones (because they increase calcium reabsorption), Nephrogenic DI
9. Side Effects: Hypokalemic Metabolic Alkalosis, Hyperuricemia (can cause gout), Hyperglycemia, Hyperlipidemia
10. Video: https://www.youtube.com/watch?v=lW8xQZtQmXI&t=170s
Identify the target site and uses of potassium-sparing diuretics (Amiloride, Spironolactone)
1. Inhibit Cortical Collecting Duct Na reabsorption
2. Cells here absorb Na via epithelial Na Channels (ENaC) on the luminal side
3. Normlly, Na influx across the luminal side leaves the lumen-negative potentialà Drives the reabsorption of Cl and
efflux of K
4. Cytoplasmic Na is brought into blood via Na/K ATPase on the basolateral side
5. Gene expression and surface localization of ENaC is modulated by Aldosterone
a. Aldosterone binds to an intracellular mineralocorticoid receptorà Increases expression of genes that
encode for ENaC and Na/K ATPase
6. Mineralocorticoid Receptor Antagonists (spironolactone and epilerinone)
a. These inhibit the effects of Aldosterone and decrease the expression of ENaC on the luminal side and Na/K
ATPase on the basolateral sideà Decrease reabsorption of Na and H2O while limiting the excretion of K
7. Direct ENaC Inhibitors (amiloride, triamterene)
a. Inhibit Na influx through ENaC on the luminal sideà decrease driving force for potassium secretion
8. Weak diuretics
9. Video: https://www.youtube.com/watch?v=-oOAxbAZJrU

Identify the target sites for vasopressin (ADH)

1. Nonapeptide (9 peptides)
2. Released from the posterior pituitary into systemic circulation in response to increased serum osmolarity or reduced
plasma volume
3. Under normal physiologic conditions- mostly plays a role in water balance, not so much vascular regulation of BP
 4. In shock states- important vasoconstrictor mechanism
5. Therapeutic uses: Central Diabetes Insipidus, Bleeding abnormalities, Asystolic Cardiac Arrest, Septic Shock
6. Acts on V1, V2 and V3 and oxytocin-type receptors
7. Half life= 10-35 minutes
a. Metabolized to inactive products of peptidases in the liver and kidney
8. Increase water permeability in the Collecting Duct and DT but inducing translocation of AQPNs to the luminal
membrane
9. Increases peripheral vascular resistance
Vasopressin Receptors
1. V1- on vascular smooth muscle of systemic, splanchnic, renal and coronary circulations, myometrium and platelets
a. G-protein coupled receptors àphospholipase C via Gq G-protein àincrease in intracellular calcium
b. -Major effect: vasoconstriction (magnitude dependent on vascular bed)
2. V2- in the distal tubule and collecting ducts
a. G-protein-coupled receptors à Gs G-proteinà adenylate cyclaseà cAMPà PKA
b. Major effect: mobilization of aquaporin channels
3. V3 receptors - mainly in the pituitary
a. Gq-coupled G-protein receptors à increase intracellular Ca2+ when activated
b. Involved in ACTH release
c. May act as a neurotransmitter or mediator involved with memory consolidation or retrieval and body
temperature regulation

Identify clinical applications for the drugs - desmopressin, mannitol.

Mannitol
1. Osmotic diuretic
2. Sugar alcohol that doesn’t cross cell membranes
3. Inhibits sodium and water reabsorption in the proximal tubule and Loop of henle
4. Causes greater water loss compared to sodium and potassium
5. Indications: head injury (can lower intracranial pressure), Glaucoma related eye surgery
a. Not really used for edema
6. Side effects: water deficit hypernatremia

Desmopressin
1. Synthetic analog of arginine vasopressin
2. Metabolism is slower than AVP
3. Selectivity for V2 receptors and translocation of AQPNs to luminal surface
a. 10x antidiuretic action f AVP but 1500x less vasoconstrictor action
4. Tx for central diabetes insipidus and primary nocturnal enuresis

Renal Challenges I- Osmolarity Homeostasis Friday

To help avoid confusion: Please note that there are 3 names for the same, identical compound:
Antidiuretic hormone (ADH) = Arginine Vasopressin (AVP) = Vasopressin