KIDNEY (EXCRETORY SYSTEM), AND ACID-BASE BALANCE

- DR. VIVEK NALGIRKAR

PROFESSOR, PHYSIOLOGY

Table of contents

• Section 1: Introduction, Structure of nephron, JG

apparatus, Renal circulation, concept of“clearance”
• Section 2: Glomerular filtration rate (GFR) ~ Factors
determining and influencing GFR;measurement of
GFR
• Section 3: Tubular functions ~ Segment-wise functions;
Handling of solutes and water bynephron
• Section 4: Mechanism of formation of concentrated urine
~ Countercurrent multiplication and countercurrent
exchange; role of ADH
• Section 5: Urinary bladder, micturition, and
cystometrogram
• Section 6: Acid-base balance: Buffer systems in the body,
role of kidney
 Section 1

Introduction

Learning objectives:

- To learn structure of a nephron and peculiarities of renal circulation

- To understand methods in renal Physiology

Though kidney is primarily an excretory organ, it performs a number of

functions that are crucial for homeostasis ~

➢ Regulation of body fluid volume and osmolality,

➢ pH regulation
➢ regulation of electrolyte composition,
➢ gluconeogenesis
➢ Endocrine function - synthesis of erythropoietin, vitamin D; also,
synthesis of renin (an enzyme; a component of RAAS)

[Kidney is a bean-shaped organ; there are two kidneys in humans, located retroperitoneally in
the lumbar region. A kidney has an outer cortex and an inner medulla. Medulla has further sub-
regions ~ outer & inner.]

• Nephron: The basic functional unit –

[Fig: Nephron. Blood flows into glomerulus via afferent arteriole, and is drained out via
efferent arteriole – shown as small arrows. Note: At the start of DCT, a small portion is shown
in thick red color; it is macula densa. Also note: Renal medulla has an outer region and an
inner region. Collecting duct is in the outer medulla and in the inner medulla – inner
medullary collecting duct (IMCD). Refer to text for further details.]

- There are about 1 million nephrons in each kidney.

- A nephron consists of a filtering component called the renal corpuscle
and a system of tubules that extends from the renal corpuscle. The renal
corpuscle has a vascular pole – the glomerulus (a tuft of capillaries), and
a renal (or urinary) pole – the Bowman’s capsule. As blood enters the
glomerulus via afferent arteriole, about 20% of the plasma filters into
 the Bowman’s capsule. The remaining blood leaves the glomerulus via
the efferent arteriole.
- The afferent arteriole is short and wide; the efferent arteriole is narrow
and long. Hence, glomerular capillary pressure is much higher, which
favors filtration.
- All components of plasma, except proteins, are filtered into the
Bowman’s capsule.

[Fig: Structural components of a nephron. Renal artery gives off afferent arteriole
which brings blood into glomerular capillaries. Glomerular filtrate comes into
Bowman’s capsule from where it starts flowing down in tubules; now it is called
tubular fluid. It flows through the PCT, loop of Henle, and DCT. Urine is finally formed
in the collecting duct. NOTE: Ascending limb of loop of Henle has a thin portion and
then a thick portion. Thick ascending limb (TAL) of loop of Henle leads to distal
convoluted tubule (DCT).]

- The filtrate then flows through the tubules – the first part is proximal
convoluted tubule (PCT) and proximal straight tubule. Then, the U-
 shaped loop of Henle, which leads to distal convoluted tubule (DCT), and
finally the collecting tubules drain into the collecting duct. The various
segments of tubules reabsorb the filtered components of plasma that
are needed to be retained in the body. Some substances are secreted
from the blood into the tubular fluid, to be excreted into the urine. Final
composition of urine is decided at the collecting duct.
- “Duct of Bellini”: Several collecting tubules, from different nephrons,
join to form the duct of Bellini, which opens at the apex of the renal
pyramid.
Tip of the medullary pyramid forms a renal papilla.
Each renal papilla —> drains its urine into a minor calyx
Minor calices unite to form a major calyx —> urine then flows into the
renal pelvis, from where it is propelled down the ureters by peristaltic
movements.

Steps in the urine formation:

1. Glomerular filtration – Except for proteins, all the contents are

removed from plasma by glomerular filtration.
2. Tubular reabsorption – As the filtrate starts flowing down into the
tubules, the substances required by the body are absorbed back into
blood.
3. Tubular secretion – Some substances that are to be eliminated out of
the body are secreted from blood into the tubular fluids. Substances
not reabsorbed and the substances secreted will be finally excreted
in urine.

Final urine = (glomerular filtration + tubular secretion) – (tubular reabsorption)

Video link ~ Final urine composition is “net” of the three processes

 The glomerular filtration barrier:

Glomerular capillaries filter out plasma with most of its constituents; however,
there is a barrier, called filtration barrier, that needs to be crossed so as to reach
the Bowman’s capsule.

- It prevents the passage of cells and high-molecular-weight proteins into

the glomerular ultrafiltrate so that they are not lost into the urine.
- The barrier is made up of 3 layers: (refer to figure)
1. Endothelium of the glomerular capillaries:- It has pores or
fenestrae that allow passage of molecules in filtrate.
2. The basement membrane of the capillaries:- There are negative
charges on the constituents of the basement membrane. Plasma
proteins, being negatively charged, do not get filtered due to
these negative charges on the basement membrane.
3. Visceral epithelial cells or podocytes, with their foot processes
that overlie the basement membrane:- There are slit pores
between the adjacent foot processes. These slit pores are bridged
by filtration slit diaphragm. Nephrin is an important constituent of
the slit diaphragm.

Video link ~ Glomerular filtration barrier

[Fig: Glomerular filtration barrier. It is made up of endothelial cells, basement membrane,
and epithelial cells or podocytes. Refer to text.]

▪ Permeability of the filtration barrier:

- Size (or diameter) and electrical charge of the molecules determine
whether they will cross the filtration barrier and appear in the filtrate in
Bowman’s capsule.
- Molecules less than 4 nm in diameter can cross the filtration barrier;
those with more than 8 nm in diameter do not get filtered.
- Anionic molecules are repelled by the negative charges on basement
membrane and on slit diaphragm; hence, they are not filtered out.
Cations can cross the filtration barrier with relative ease.
• Applied Physiology:
1. Nephrotic syndrome:
- It is a clinical condition resulting from a variety of diseases that cause
glomerular injury.
- Damage to basement membrane and loss of its negative charges leads
to filtration of proteins and their consequent loss into urine.
 - Proteinuria, loss of albumin (hypoalbuminemia) lead to decrease in
plasma colloid osmotic pressure in systemic capillaries. It results in
generalized edema.

Types of nephron:

A kidney has two regions: An outer cortex and an inner medulla.

- 85% nephrons are cortical (most part of nephron in the cortex, short
loops);
- 15% are juxtamedullary (glomeruli at the junction of cortex and
medulla, long loops).
Cortical nephrons are fully functioning under normal conditions;
juxtamedullary nephrons work in conditions of stress. For instance,
concentrated urine formation, when body needs to conserve water, is
the function of juxtamedullary nephrons.
[Figure: Types of nephron. The juxtamedullary nephron has a glomerulus at the border of the
renal cortex and medulla; and a long loop that goes deep into the inner medulla. The cortical
nephron has a glomerulus superficial in the cortex and a short loop of Henle.]

Juxtaglomerular apparatus (or JG apparatus):

- It is a component of tubuloglomerular feedback mechanism that is

involved in the autoregulation of renal blood flow (RBF) and the
glomerular filtration rate (GFR).
- In each nephron, the thick ascending limb of loop of Henle touches the
vascular pole of the glomerulus; at this site is the JG apparatus. It
consists of the following structures -

[Fig: Formation of JG apparatus. Last part of thick ascending limb (TAL) of loop of
Henle comes near afferent arteriole, to form JGA.]

▪ The granular juxtaglomerular cells in the afferent arteriole. They

are modified smooth muscle cells (of the vessel). These cells
synthesize and secrete renin.
 ▪ The macula densa at the end of the thick ascending limb and the
initial portion of DCT. It consists of densely crowded epithelial
cells of the tubule. These cells monitor the composition of the
fluid in renal tubules at this point.
▪ The extraglomerular mesangial cells. [or ‘Lacis cells’] They may
transmit information from macula densa cells to the granular
cells.
➢ Functional significance of JG apparatus:
1. Tubuloglomerular feedback mechanism: [Tubule →
glomerulus; negative feedback]
▪ It is a negative feedback system that stabilizes renal
blood flow and GFR.

Video link ~ Tubulo-glomerular (TG) feedback

Video link ~ Glomerulo-tubular (G-T) balance

 Increased renal Increased GFR
blood flow

Increases NaCl delivery

to macula densa

Increased NaCl reabsorption

and increased ATP
breakdown

ATP → ADP → AMP → adenosine

Renal blood flow

decreases
Adenosine reaches Constriction of
afferent arteriole afferent arteriole GFR decreases

[Tubuloglomerular (TG) feedback mechanism.]

[Two important points should be noted here -
A. Na+ reabsorption from renal tubules involves active transport process, and
it is energy-dependent. In fact, ATP breakdown by kidneys is directly
proportional to the amount of Na+ load presented to the tubules.
B. Adenosine is a vasodilator elsewhere in the body. However, in kidneys, it
causes vasoconstriction (by acting via different types of receptors).]

2. Regulation of blood volume and blood pressure:

▪ The granular or JG cells are sensitive to stretch; they
function as intra-renal baroreceptors. A decrease in
 pressure in the afferent arteriole can be sensed by the
granular cells.

Decrease in blood volume and

blood pressure (e.g. due to
hemorrhage, diarrhea, etc)

Sensed by
the granular
(JG cells) of
the JG
apparatus JG cells secrete
RENIN

Blood

ANGIOTENSINOGEN Angiotensin I

ACE
(lungs)

Angiotensin II

Secretion of
aldosterone by
adrenal cortex

Blood volume
increases; blood
Aldosterone acts Na+ and water pressure
on renal tubules reabsorption increases

[Renin-angiotensin-aldosterone system (RAAS) in regulation of blood volume and BP.]

Renal circulation

Functional anatomy:

- Abdominal aorta —> Renal artery —> afferent arteriole

- Afferent arteriole brings blood into glomerular capillaries; some amount
of plasma, with its constituents, is filtered out and remaining blood
leaves glomerulus via efferent arteriole. Note: Afferent arteriole is short
and wide; efferent arteriole is long and thin.
- Efferent arteriole breaks up into peritubular capillary network.
Substances are reabsorbed from or secreted into corresponding renal
tubule by peritubular capillaries. Some straight vessels – vasa recta –
emerge from efferent arteriole; they are in close proximity of
descending and ascending limb of loop of Henle.

Peculiarities of renal circulation:

(Some of these features are exceptional, seen only in renal circulation; others are
outstanding features.)

o Kidneys have a dual capillary bed – Glomerular capillaries and peritubular

capillaries. (Generally, an organ has a single capillary bed.)
o Capillaries drain into arterioles (glomerular capillaries —> efferent
arteriole). Everywhere else in the body, capillaries drain into venules.
o Very high blood flow: Kidneys receive about 22%-25% of the cardiac
output; a very high fraction considering that kidneys weigh only about 1-2%
of the body weight. In terms of blood flow per 100 gm of tissue, the renal
blood flow (RBF) is 4 times greater compared to blood flow to liver or
exercising muscle and 8 times the coronary blood flow. (Renal blood flow ~
300-400 mL/100 gm of tissue/min.)
o Autoregulation of blood flow: (also described in TG feedback) ~ In the face
of fluctuating systemic BP, within a range of 80-180 mm Hg, renal blood
flow is held constant by intrinsic mechanisms.
 o Capillary hydrostatic pressure, compared to elsewhere, is highest in
kidneys. Glomerular capillary hydrostatic pressure is 60 mm Hg.
[Explanation: Afferent arteriole is wide and efferent arteriole is narrow.
This causes accumulation of blood in glomerular capillaries, resulting in a
high hydrostatic pressure.]
o Capillary filtration coefficient is highest in kidneys: 12.5 ml/min./mm Hg [It
is the rate at which capillaries filter out fluids, per unit time. The
fenestrated glomerular capillaries have a very high rate of filtration.]
o A-V O2 difference is least in kidneys ~ 1.7 mL of O2/100 mL of blood;
(elsewhere, it is 5 mL/100 mL of blood).
o In kidneys: Blood flow regulates the metabolic rate. (Elsewhere, metabolic
rate regulates the blood flow to an organ.) [Explanation: Increased blood
flow in glomerulus → more Na+ filtered → more Na+ load to the tubules. O2
consumption is directly proportional to Na+ reabsorption by tubules (role of
Na+-K+ ATPase). Thus, O2 consumption and metabolic rate is proportional to
blood flow, in the case of kidney.]

~ Comparing between renal cortex and renal medulla:- Blood flow is greater in the
cortex (all the glomeruli are located in cortex); O2 extraction ratio is slightly higher
in the medulla.

Autoregulation of renal blood flow: (Note: The vital organs – brain, heart, and
kidney – exhibit the feature of autoregulation.)

▪ In the range of 80 mm Hg-180 mm Hg, renal blood flow (RBF) remains

constant even if there are fluctuations in systemic BP.
▪ Outside this range, changes in RBF occur parallel to the changes in BP.
▪ Two possible mechanisms involved in renal autoregulation: (a) myogenic
mechanism, and (b) Tubuloglomerular (TG) feedback mechanism.
(a) Myogenic (stretch) mechanism:
- Increased BP (possible increase in RBF)—> stretch of the blood vessel
walls —> smooth muscle stretched —> contraction of smooth muscle —
> decreased vessel diameter; decreased (maintained) blood flow.
Decrease in BP will have opposite effects.
 (b) TG feedback: (refer to JG apparatus for details)
- Increased RBF —> increased filtration of Na+ —> tubular load for Na+
reabsorption sensed by macula densa —> signal sent (from tubule) to
glomerulus —> constriction of afferent arteriole —> decrease in blood
flow.

Video link ~ Myogenic mechanism; role of ‘stretch-activated Ca++ channel’

➢ Investigative concepts in renal physiology:

1. “Clearance” measurements –
- “Clearance” is a measure of the theoretical volume of plasma that is
completely cleared of a given substance per unit time by the kidneys.
It is the ratio of renal excretion rate of the substance to its
concentration in the plasma.
- For a substance “x” – Plasma concentration is Px.
Its urinary concentration is Ux, and total volume of urine is V.
Then, its total excretion rate will be [Ux × V]. {E.g. if urinary
concentration is 2 mg/mL, and urine volume is 100 mL/min., then total
excretion of the substance in urine would be 2 × 100 = 200 mL/min.}
Clearance rate of the substance would be:

[𝑈𝑥 𝑋 𝑉]
𝐶𝑥 =
𝑃𝑥

{It means, the substance ‘x’ has a plasma concentration of Px, and from the
plasma, ‘x’ is removed and excreted into urine at a rate of [Ux X V].}

Video link ~ Clearance is not a fraction; it is not a fractional excretion of

a substance intourine
~ Inulin clearance is used to measure GFR: (Cinulin = GFR)

- Inulin is a fructopolysaccharide.

- When injected, it does not bind to plasma proteins.

- It is freely filtered at the glomerulus.

- It is neither secreted nor reabsorbed by the tubules.

Inulin is freely filtered at glomerulus. Then, it is neither reabsorbed nor secreted

by the tubules. It means, all the filtered amount is excreted in urine. All the
urinary inulin is coming as filtered amount. Thus, from its urine level, its rate of
filtration can be assessed. And, its rate of filtration is almost same as “glomerular
filtration rate” (GFR) (since it is freely filtered at glomerulus, just like plasma).
Hence, inulin is used to measure GFR.

Other substances that can be used: mannitol, iothalamate.

However, all these have to be injected I.V.

In clinical setting, endogenous creatinine clearance is used to measure GFR, most

commonly.

Creatinine is formed from muscle creatine; it is excreted in urine as a waste

product.

Creatinine clearance gives an approximate value of GFR.

{There are two issues in using creatinine clearance as a measure of GFR. (i)
Numerator: Urinary excretion rate of creatinine (Ucr X V) is an overestimation of
GFR. Reason: Some 10 to 15% of creatinine is also secreted by tubules. Thus,
urinary level of creatinine is NOT coming only from the glomerular filtration. (ii)
Denominator: Plasma concentration of creatinine (Pcr) is a false overestimate.
Reason: Standard colorimetric methods for determining plasma creatinine
measure other chromogens (acetone, proteins, ascorbic acid, pyruvate) in plasma,
Video link ~ Inulin is the best substance to measure GFR; creatinine is most
commonly used
in addition to creatinine (“Jaffe reaction”). Thus, plasma creatinine is generally an
overestimated value. The two error components cancel out so that creatinine
clearance is considered to be an approximation of GFR.}

• Measurement of renal plasma flow (RPF)and renal blood flow (RBF):

- The substance used is para-amino hippuric acid [PAH].
- We are interested in measuring renal blood flow (RBF). However, the
substance that is used for this purpose (PAH) gets dissolved in PLASMA
and enters kidneys. Hence, it will indicate the renal plasma flow (RPF),
from which RBF can be calculated.
- Most important characteristic of PAH is this – Its renal vein
concentration is zero. It means, once PAH comes in renal arterial blood,
then by glomerular filtration and tubular secretion, all of it (100%)
comes into urine. Hence, its urinary excretion rate can reflect the renal
blood flow or renal plasma flow
• Renal blood flow is then calculated by the equation:

1
𝑅𝐵𝐹 = 𝑅𝑃𝐹 𝑋
1 − 𝐻𝑒𝑚𝑎𝑡𝑜𝑐𝑟𝑖𝑡

(Between plasma and blood, difference is that of hematocrit. Hence, from the
plasma flow, blood flow can be calculated by the above equation.)
Video link ~ Criteria for the use of any substance (PAH) for
measurement of RPF; use of FICK’s equation

————————————————————————————————————
 Section 2

Glomerular filtration rate (GFR)

Learning objectives:

1. This topic needs a clear understanding of Starling’s forces acting on

capillaries. Hence, first objective is to understand these forces as they
cause formation of glomerular filtrate.
2. Another learning objective is to understand Physiological factors such as
diet, and pathological factors, such as drugs & diseases, that influence
GFR.

Introduction:

- Ultrafiltrate is a filtrate formed under pressure. Glomerular filtration is

an ultrafiltration process.
• Definition: Glomerular filtration rate (GFR) is the amount of filtrate
formed by the two kidneys per unit time.

➢ Normal GFR = 125 mL/min. or 180 L/day.

• Note that: 180 L of filtrate is formed every day. But the final urine volume
per day is only about 1 to 1.5 L. It means, almost 178 L of the filtered
volume is reabsorbed by the tubules.

~ As blood enters glomerular capillaries, plasma along with its solutes is filtered
into the Bowman’s capsule first; from there it starts flowing down the tubules
(PCT).

Filtration of substances across a capillary membrane is governed by the

“STARLING’S FORCES” acting in and around the capillaries. Let’s recall the
Starling’s forces acting on any capillary bed.
 Plasma
Capillary
colloid
hydrostatic
osmotic

Interstitial Interstitial STARLING’S FORCES:

fluid fluid colloid
hydrostatic osmotic 1. Hydrostatic
pressure pressure pressure

2. Colloid pressure

[Fig: It shows Starling’s forces that act in and around capillaries; these forces cause
movement of fluid out of a capillary and back into the capillary. (1) Hydrostatic pressure:-
(“hydro” “static”) This is a pressure exerted by accumulated fluid. Greater the amount
accumulated, higher will be the pressure. This is a force that pushes the fluid out of the
compartment. Thus, capillary hydrostatic pressure will push the fluid out of the capillary;
interstitial fluid hydrostatic pressure will push the fluid from interstitium, back into the
capillary. (2) Colloid osmotic pressure:- It is exerted by proteins. It pulls fluid toward it by
osmosis. Thus, plasma colloid osmotic pressure pulls the fluid into the capillary; interstitial
fluid colloid osmotic pressure pulls the fluid out of the capillary, into the interstitium.]

With the understanding of these forces, we can now discuss the factors that
determine the GFR. In the place of interstitial fluid, we will have fluid in the
Bowman’s capsule.

Also note:- (1) Forces that cause the fluid to move out of the capillary are the
forces that favor filtration; and, forces that tend to move the fluid back into
capillaries are the forces that oppose filtration. (2) Of the 4 forces mentioned,
interstitial fluid colloid osmotic pressure is not considered here. Since proteins
normally do not get filtered out into Bowman’s capsule, there won’t be
‘Bowman’s capsule colloid osmotic pressure’.

1. Factors favoring filtration at the glomerular capillaries:

 Glomerular CAPILLARY HYDROSTATIC PRESSURE. It tends to push the
plasma fluid out of the glomerular capillaries, into the Bowman’s capsule.

This pressure is about 60 mm Hg.

2. Factors opposing filtration at the glomerular capillaries:

a. Plasma colloid osmotic pressure: It is exerted by the plasma proteins (of

the glomerular capillaries). It tends to pull the fluid back into the
capillaries; thus it works in the opposite direction (that is, against
filtration). It is about 32 mm Hg.

b. Bowman’s capsule hydrostatic pressure: It is exerted by the filtrate

accumulated in the Bowman’s capsule. It tends to push the fluid back
into the glomerular capillaries, thus opposing filtration. It is about 18
mm Hg.

• (I) Pressure favoring filtration = 60 mm Hg;

(II) Pressure opposing filtration = (32 + 18 =) 50 mm Hg.

Thus, net filtration pressure = [(I) – (II)] = +10 mm Hg. Filtration force will
be exerted by this net pressure.

• For the glomerular capillaries: there is proportionality constant for

filtration, called “capillary filtration coefficient”.

Capillary filtration coefficient = 12.5 mL/min./mm Hg. [For every 1 mm Hg

filtration pressure, the capillaries filter out 12.5 mL of fluid per minute.]

The total “net” filtration pressure is 10 mm Hg. Thus, capillaries will filter
12.5 × 10 = 125 mL/min. Normal GFR = 125 mL/min.

o Filtration fraction:
GFR
filtration fraction =
RPF
- Renal blood flow ≈ 1200-1250 mL/min.
- Renal plasma flow would be about 625 mL/min. (plasma is 55% of any
blood volume.)
 - Out of this 625 mL of plasma, 125 mL filtrate is formed every minute.
Hence, filtration fraction = 125/625 = 20% or 0.2

Video link ~ Filtration fraction

Video link ~ How to calculate total filtered amount of a substance per unit
time?
Factors influencing GFR –

{The factors that modify the hydrostatic factor or colloid osmotic pressure will
influence GFR. Remember:- Greater the amount of blood in glomerular capillaries
—> higher will be the hydrostatic pressure in glomerular capillaries —> GFR will
increase.}

1. High protein diet increases renal plasma flow and GFR.

2. Blood flow into the glomerulus is an important influencing factor.

- Afferent arteriole brings blood into the glomerular capillaries. Dilation

of the afferent arteriole will increase blood flow into the glomerulus.
Greater blood flow in the glomerular capillaries → increases hydrostatic
pressure in glomerular capillaries (favors filtration) → This will increase
the GFR.

- Vasodilators: Nitric oxide [NO], PGs, etc – increase blood flow → ↑ GFR

3. Constriction of the efferent arteriole:

(A) Moderate constriction: Constriction (narrowing) of the efferent

arteriole → decreased blood flow out of the glomerular capillaries →
blood accumulates within the glomerular capillaries → increased
capillary hydrostatic pressure in the glomerulus → increased GFR.
(B) However, severe constriction of efferent arteriole decreases GFR. As
blood flow out of the glomerulus severely restricted → proteins
accumulate in the glomerulus within glomerular capillaries → colloid
 osmotic pressure will increase in glomerulus, opposing filtration → ↓
GFR.
4. Any factor that increases hydrostatic pressure in Bowman’s capsule will
decrease the GFR.
- Obstruction to the tubular flow → fluid will accumulate in the Bowman’s
capsule → ↑ hydrostatic pressure in the Bowman’s capsule → opposes
filtration, GFR decreases.
E.g. obstruction anywhere along the urinary tract because of stones,
ureteric obstruction, or prostate enlargement.
5. GFR decreases with advancing age. With increasing age → loss of
functioning nephrons → ↓ GFR.
6. GFR decreases due to a fall of blood pressure below 60 mm Hg, as in
circulatory shock.
7. It also decreases with erect posture, emotions, pain, exercise, cold stress,
etc.

Measurement of GFR:

- (Also refer to discussion on ‘clearance’) A substance that is freely filtered

at glomerulus, and then neither reabsorbed nor secreted into tubules, is
said to be ideal for measuring GFR.
- Inulin is most ideal for this purpose. However, inulin has to be injected
(and it may cause allergic reaction). Creatinine is most commonly used
to measure GFR.
- Creatinine clearance is an overestimate of the actual GFR by about 5%-
10%.
 RBF or RPF GFR Filtration
fraction
(GFR/RPF)

1. Dilation of Increases Increases Constant

afferent
arteriole

2. Moderate Decreases (blood Increases Increases

constriction of accumulates in
efferent glomerulus)
arteriole

3. Severe, Decreases (blood Decreases (due to Constant

sustained accumulates in increased plasma
constriction of glomerulus) colloid osmotic
efferent pressure)
arteriole

4. Nephrolithiasis No change Decreases (due to Decreases

increased
hydrostatic
pressure in
Bowman’s
capsule)

[Note: If blood leaving glomerulus per unit time decreases, then blood coming in
glomerulus per unit time will also decrease. Hence, there will be an overall
decrease in blood flow with constriction of efferent arteriole.]

Clinical application:

- Decrease in GFR may occur from pre-renal, renal, and post-renal causes.
1. Pre-renal causes: (pre = before; i.e., before blood enters kidney and
starts forming urine) E.g., decreased circulating blood volume,
dehydration, reduced cardiac output. These conditions result in a
decrease in RBF
2. Renal causes: E.g., Glomerulonephritis.
3. Post-renal causes: (post = after; i.e., after the process of urine
formation) E.g., Urinary tract obstruction
 Section 3
Tubular functions

Learning objectives:
1. To understand the process of tubular reabsorption of various substances
from various segments of a nephron.
2. To understand secretion of some substances into tubules, to be
eliminated into urine.

Tubular function – (Reabsorption and secretion)

- Once the filtered load starts flowing down the tubules, all the
substances required by the body are absorbed back into blood from
various portions of the renal tubules.
- Some substances from blood, to be eliminated into urine, are secreted
into the tubular fluid.

~ Whether a substance was reabsorbed or secreted, and how much of it was

reabsorbed or secreted, can be found out by the data:

Px = Plasma level of the substance “x”

GFR = Glomerular filtration rate

Ux = Urinary concentration of “x”; V = Total volume of urine

(Px × GFR) = Total filtration of the substance at the glomerulus ---------[A]

(Ux × V) = Total excretion of the substance in urine ---------------------- [B]

If [A] > [B], filtered load of the substance is greater than the final excretion of the
substance. It means, the remaining amount was REABSORBED. {E.g. if 100 mg was
filtered and 80 mg appears in urine, the remaining 20 mg was reabsorbed.}

If [B] > [A], amount of the substance excreted in urine is greater than the amount
that was filtered at glomerulus. It means, additionally some substance was
secreted into the tubules. {E.g. 100 mg appears in urine and out of it 80 mg came
from glomerular filtration, additional 20 came from TUBULAR SECRETION.}

• Sodium reabsorption along the nephron:

Mechanism: Na+ reabsorption occurs via transcellular as well as paracellular
pathway. Paracellular transport of Na+ is driven by the transepithelial
electrochemical gradient for Na+.
For the transcellular pathway:

[Fig: Na+ reabsorption is a two-step process – (1) Na+/K+-pump, located on the

basolateral membrane, removes Na+ from inside the cell (and sends it into
blood). Due to this, the Na+ concentration within the cell would decrease. (2) On
the apical membrane, there is a transporter (channel or carrier) which will move
Na+ from the lumen into the cell, down its concentration gradient.]

Na+ reabsorption from tubules occurs as a two step process.

The epithelial cell lining the tubule has two sides: 1. Basolateral membrane
facing the blood vessel, and 2. Apical membrane facing the lumen of the
tubule.
 - In the basolateral membrane, there is Na+-K+-pump. It is an active
transporter. It causes Na+ from the cell to move out into the blood
vessel. This decreases the Na+ concentration inside the cell. Na+ from the
tubular fluid can now move into the cell, down its concentration
gradient (high-to-low concentration).
- In the apical membrane, there is a transport protein (channel or carrier).
This transporter will cause Na+ from the tubular fluid to move into the
lining cell, down the concentration gradient.
o Note: The Na+ transport through the apical membrane is of different types
at different places along the nephron.
- In the distal part of the nephron (DCT, CD): The apical membrane has
Epithelial Na+ Channel [ENaC]. Na+ from the tubular fluid diffuses
through this ENaC to enter the epithelial lining cell. (Then, Na+ is
removed from the cell, into the blood, by the Na +-K+ pump located at
the basolateral membrane.)
- In the loop of Henle: In the thick ascending part of the loop of Henle,
there is a secondary active transporter – Na+-K+-Cl- cotransporter
[NKCC]. It transports Na+ from the tubular fluid into the cell. It
transports 1 Na+: 1 K+: 2 Cl- ions (that is, co-transport of K+ & Cl- along
with Na+).
- In the early distal tubule: There is a secondary active transporter called
Na+-Cl- cotransporter [NCC]. It causes co-transport of Cl- along with Na+,
from the tubular fluid into the cell, in ratio of 1 Na+: 1 Cl-.

Video link ~ Aldosterone and Na+ reabsorption

Video link ~ Mechanism of action of diuretics – Loop diuretics, thiazide

diuretics
 Segment Fraction of Na+ entry across Regulatory
filtered sodium the apical hormones
reabsorbed membrane
Proximal tubule 67% Na+-H+ exchanger Angiotensin II,
(NHE-3), Na+- Epinephrine, NE,
cotransport with dopamine
amino acids and
organic solutes
Loop of Henle 25% NKCC transporter Aldosterone
(1Na+-1K+-2Cl-
symport)
Distal tubule ~ 4% NCC transporter Aldosterone
(1Na+-1Cl-
symport)
Late distal tubule ~ 3% ENaCs (Epithelial Aldosterone, ANP,
and collecting sodium channels) urodilantin
duct
{NE = Norepinephrine; ANP = atrial natriuretic peptide}

• Water reabsorption along the nephron:

o Water reabsorption from various segments of a nephron follows the Na+

reabsorption pattern.

o 67% in proximal tubule, 10-15% in the loop of Henle, and remaining (8 to

18%) in the collecting duct.
(I) Water reabsorption from the PCT:
 - As the glomerular filtrate starts flowing down the proximal
tubule, its osmolarity is about 300 mOsm (same as that of
plasma). Glomerular filtrate is ISOTONIC to plasma.
- In the PCT, 65-70% of the total filtered Na+ and 65-70% of the
total filtered water is reabsorbed.
- Since same proportion of Na+ and water are absorbed from the
tubular fluid in the PCT, its osmolarity remains the same. That
is, tubular fluid remains ISOTONIC at the end of PCT
(osmolarity = 300 mOsm).
- Also note: Irrespective of the body’s water status or water
needs, 65-70% of the filtered water does get absorbed from
PCT. Hence, it is termed obligatory water absorption.
(II) Water reabsorption from the loop of Henle:
▪ The descending limb of loop of Henle is permeable to
water. 10-15% of the total filtered water is absorbed
from this segment.
▪ The thick ascending limb of loop of Henle is
impermeable to water. Na+, K+, and Cl- get absorbed
from tubular fluid in this part, but water is NOT
absorbed. Thus, in this segment, tubular fluid has less
solutes and relatively more water. Hence, this segment
is also called “diluting segment”.
▪ The fluid that leaves the loop of Henle and enters the
early distal convoluted tubule (DCT) is HYPOTONIC
(more of water relative to solutes).
(III) Water reabsorption in the DCT and collecting duct:
- As the filtered fluid reaches this segment of the nephron,
almost 85% water has already been absorbed from it.
- Once water is absorbed from this segment, final urine
composition (its water content) will be decided.
- Water reabsorption from this segment is dictated by the
body’s current water status and water needs. If body needs
water or plasma has become hypertonic (more solutes relative
 to water), water will be absorbed from the DCT and CD into
blood.
- If plasma is hypotonic (more water relative to solutes), then
water will NOT be absorbed from this segment (or absorbed
minimally).
- Hence, water reabsorption by this part of the nephron is called
facultative water reabsorption (water reabsorption according
to body needs).
▪ Facultative water reabsorption from DCT and CD is regulated by the
antidiuretic hormone [ADH].
- If plasma is hypertonic → water needs to be reabsorbed into
blood;
Hypertonic plasma is sensed by the osmoreceptors in
hypothalamus → release of ADH from posterior pituitary →
ADH reaches kidney → causes antidiuresis (water reabsorption
from DCT & CD).
- Mechanism of action of ADH:
ADH causes insertion of aquaporin channels in the tubular
wall. Water absorption from tubules is facilitated; it occurs
through these aquaporins.
- Note: In the absence of ADH – 2 to 3% of water is absorbed by
this segment. Thus, [85% water absorbed from earlier
segments] + [2-3% absorbed from DCT & CD] ≈ 88% water will
be reabsorbed from the glomerular filtrate; remaining will
form the urine volume.
- In the presence of ADH – 10 to 12% of water is absorbed from
this segment. Thus, [85% water absorbed from earlier
segments] + [10-12% absorbed from DCT & CD] ≈ 99% water
will be reabsorbed from the glomerular filtrate; remaining will
form the urine volume.
Tubular handling of various other substances:

▪ Proximal tubule: {Reabsorption and secretion}

1. Handling of the filtered HCO3-:

- Plasma HCO3- = 24 mEq/L. GFR = 180 L/day. Total filtered

amount of HCO3- = (Px× GFR) = 4320 mEq/day.

- All of this bicarbonate has to be reabsorbed and taken back

into the body under normal circumstances.

- This bicarbonate is reabsorbed from the PCT.

- It can be reabsorbed only when it first combines with H + ions in

the tubular lumen. Hence, to facilitate the absorption of HCO3 -,
4320 mEq of H+ is secreted every day by the PCT.

2. Glucose and amino acids:

- Glucose and amino acids are completely reabsorbed from the

proximal tubule.

• By the end of the proximal tubule:

- Only 1/3rd of the filtered Na+, water, and K+ are left (2/3rd or
67% reabsorbed)

- Almost all of the filtered glucose, amino acids, and HCO3- have
been reabsorbed.

- Many solutes destined for excretion (e.g. urea) have been

concentrated.

The proximal tubule secretes organic ions:

▪ Proximal tubule secretes a large variety of organic cations and

organic anions; many of them are endogenous substances, drugs, or
toxins.
 ▪ The organic anion transporter (OAT) in the wall of the proximal
tubule causes active secretion of anions such as – penicillin, PAH,
creatinine, etc.

▪ The organic cation transporter (OCT) causes active secretion of

cations. E.g. creatinine.

[Creatinine is an unusual compound, because it is secreted by both

anion & cation transporters. The creatinine molecule bears both
negatively charged and positively charged groups at physiological
pH; that is, it is a zwitterion.]

Proximal tubule also actively reabsorbs some organic cations & anions. E.g. uric
acid. Thus, uric acid is both reabsorbed as well as secreted in the proximal tubule.

▪ Tubular transport in the loop of Henle:

- The loop of Henle reabsorbs about 20% of filtered Na+, 25% of

filtered K+, 30% of filtered Ca++, 65% of filtered Mg++, and 10-
15% of filtered water.

- Descending limb is highly water-permeable. Thick ascending

limb (TAL) is water-impermeable. TAL reabsorbs Na+, K+, Cl-.

- The NKCC transporter is present in the thick ascending limb. It

is sodium/potassium/chloride co-transporter; 1 Na+: 1 K+: 2 Cl-
are transported by NKCC (thus, it is electroneutral).

▪ Cortical collecting duct is an important site that regulates K+ excretion:

There are two types of cells in the collecting duct:

a. Principal cells – reabsorb Na+ and secrete K+; and then

b. Intercalated cells – reabsorb K+ and secrete H+
➢ When dietary K+ is low, K+ is conserved in the body by kidneys. The
intercalated cells will reabsorb more K+.
 ➢ K+ secretion is promoted by the hormone aldosterone. It increases Na +
reabsorption and consequently, increases K+ secretion. When body K+ has
increased, aldosterone will exert these actions and eliminate K+ into urine.

~ Transport maximum or tubular maximum (Tm):

- It is the maximum rate at which a substance can be transported

across the tubules, either reabsorbed or secreted.

- This limit is due to the carrier protein in the tubular wall. The carrier
protein for every substance has a finite capacity to transport a
particular substance. That is, it is saturable.

e.g. Tm for glucose (TmG) ≈ 320 mg/min. Glucose carrier can maximally transport
up to 320 mg of glucose from the tubular fluids, per min., into blood.

As the plasma glucose goes on increasing, filtered load of glucose also will
increase. [Filtered load = Px × GFR; thus, greater the plasma level – Px – greater
will be the filtered load of that substance.]

As the filtered load increases, reabsorption will also increase. However, beyond a
certain level, the reabsorption can not increase further. Reason: The carrier which
causes the transport and reabsorption of glucose will get completely saturated.

The extra amount of glucose, over and above the maximum capacity of the
transporter (TmG) will begin to appear in urine.

Note:

Renal threshold for glucose = 180 mg%. That is, when plasma glucose
exceeds 180 mg%, glucose begins to be excreted in urine. [Below this plasma level
of glucose, all the filtered glucose is reabsorbed; none appears in urine.]

If the tubular transport maximum (Tm) for glucose is 320 mg/min., tubules have
the capacity to reabsorb glucose maximally up to 320 mg/min. Then, when
plasma level exceeds just 180 mg%, why all of the filtered glucose cannot be
reabsorbed and some begins to appear in urine?

Answer to this question is: splay.

Splay is a phenomenon described in the glucose reabsorption curve. Let’s say,

plasma glucose is rising, more and more plasma glucose is getting filtered and
hence is delivered to tubules for reabsorption. It’s not as if suddenly all the
glucose carriers will be saturated at one stage, and glucose will begin to appear in
urine.

There is heterogeneity among the nephrons in their filtration capacity and

reabsorption rate. Different nephrons have different capacities to filter and then
reabsorb glucose load.

Some nephrons may have a large glomerulus but a short proximal tubule. Such
nephrons will cause glucose to appear in urine at a low plasma level of glucose.
Reason ~

- Large glomerulus → means it can filter greater amounts of glucose

per unit time.

- Short length of proximal tubule → means less number of glucose

transporters to absorb the filtered load of glucose. The transporters
saturate early and the remaining glucose begins to appear in urine.

Sodium reabsorption along the entire nephron, and potassium secretion

along the distal nephron do not have a Tm value.

Mechanism of urine formation: {Steps in urine formation}

[There is repetition of some of the points from previous section. This particular
topic explains process of urine formation in a linear, organized manner.]
 o About 1 to 1.5 L urine is formed every day.

o Urine formation involves 3 steps:

1. Glomerular filtration (or ultrafiltration)

2. Tubular reabsorption

3. Tubular secretion

Net urine formation = [(Glomerular filtration) + (tubular secretion)] – [Tubular reabsorption]

(1) Glomerular filtration:

- As blood enters the glomerulus via the afferent arteriole, a filtrate is

formed from the plasma. This filtrate is free of proteins. The remaining
blood leaves the glomerulus via the efferent arteriole.

- Glomerular filtration rate (GFR): It is the amount of filtrate formed by

the kidneys in a minute.

Normal GFR ≈ 125 mL/min., that is, 180 L/day.

GFR is measured by using following substances:

(i) Inulin (exogenously administered)

(ii) Creatinine (endogenous substance)

- Renal blood flow ≈ 1250 mL/min.; renal plasma flow (RPF) would be: 625
mL/min. (approximately). Out of this plasma flow per minute, 125 mL
filtrate is formed. Hence, “filtration fraction” = GFR/RBF = 20% or 0.2.

- Factors that favor filtration are: Glomerular capillary hydrostatic

pressure. It is about 60 mm Hg.

- Factors that oppose filtration are: (1) Plasma colloid osmotic pressure
(32 mm Hg), and (2) Bowman’s capsule hydrostatic pressure (18 mm
Hg). Total opposing force = 32 + 18 = 50 mm Hg.
 - Hence, the “net” filtration pressure = 60 – 50 = +10 mm Hg.

- Capillary filtration coefficient ≈ 12.5 mL/min./mm Hg. {For every 1 mm

Hg filtration pressure → capillaries filter 12.5 mL per minute.}

- Since total net or effective filtration pressure is 10 mm Hg, total

filtration would be: 12.5 × 10 = 125 mL/min.

- Glomerular filtrate is isotonic to plasma.

(2) Tubular reabsorption:

o 180 L of filtrate is formed every day. However, the final urine

formation is only about 1-1.5 L/day. It means, the remaining almost
178.5 L of filtrate is reabsorbed by the tubules.

a. Proximal tubular reabsorption:

▪ When the glomerular filtrate is formed, it is isotonic to

plasma (300 mOsm). This isotonic filtrate enters the
proximal tubule.

▪ 65-70% of Na+ in this filtrate and 65-70% of water is

reabsorbed in the proximal tubule. Since same
proportion of Na+ and water are reabsorbed (and same
proportion of them are left behind in the tubular fluid),
tubular fluid at the end of proximal tubule is still
isotonic.

▪ Remaining 30-35% Na+ and water enter the loop of

Henle.

▪ 65-70% of the filtered K+ is reabsorbed in the proximal

tubule.

▪ All of the filtered glucose and amino acids are

reabsorbed from the proximal tubule.
 ▪ Most of the filtered HCO3- is reabsorbed from the
proximal tubule. Major fraction of the filtered Cl - is
reabsorbed from the PCT. Ca++ (60%) and Mg++ (25%) is
reabsorbed from the proximal tubule.

b. Reabsorption in the loop of Henle:

▪ 15-20% Na+ is reabsorbed from the loop of Henle. The

remaining Na+ reaches distal nephron. All of the
remaining Na+ will be reabsorbed from the DCT and CD.

▪ Water reabsorption from the loop of Henle: The

descending limb of loop of Henle reabsorbs some 10%
water from the tubular fluids.

Thick ascending limb (TAL) of loop of Henle is

impermeable to water.

Since water is not reabsorbed from the TAL, tubular

fluids become hypotonic. This segment of the nephron is
hence called “diluting segment”. The tubular fluid
reaching early DCT is always hypotonic.

▪ 25% of the filtered K+ is reabsorbed in the loop of Henle.

Some amount of Cl- is also reabsorbed from the thick
ascending limb of loop of Henle.

▪ Ca++ (20%) and Mg++ (65%) are reabsorbed from the loop
of Henle.

c. Reabsorption from the distal nephron:

▪ Water reabsorption from the DCT and CD is under the

regulation of ADH. Depending on the osmolarity of plasma,
ADH will reabsorb water from the tubular fluids. The
remaining water will be finally excreted in urine, with
solutes dissolved in it.
 ▪ Collecting duct has two types of cells: (1) Principal cells –
They reabsorb Na+ and secrete K+; (2) Intercalated cells –
They reabsorb K+ and secrete H+.

▪ Ca++ reabsorption in the distal nephron is under the

influence of the parathyroid hormone.

[Fig: Tonicity of tubular fluids. Glomerular filtrate is isotonic to plasma. Then, from PCT, 67%
of Na+ and 67% of water is reabsorbed; i.e., equal proportion of Na + & water removed. Hence,
by the end of PCT, the tubular are isotonic. Thick ascending limb (TAL) is impermeable to
water, but Na+ is removed from TAL. Hence, fluid reaching early DCT is hypotonic. In collecting
duct, fluid may be hypertonic or hypotonic, depending on the action of ADH. If, for instance,
plasma was hypertonic and ADH acts on collecting duct to reabsorb water, the fluid in
collecting duct becomes hypertonic.]

(3) Tubular secretion:

- H+ ions are secreted in the PCT. This secretion is to facilitate
reabsorption of the filtered HCO3 -.

- Proximal tubule secretes many organic ions; endogenous substances

(e.g. creatinine), toxins, and drugs are secreted by this segment.

- Uric acid can be secreted as well as reabsorbed from the proximal

tubule.

- H+ ions are secreted by the intercalated cells in the collecting duct. This
secretion is to achieve acidification of urine (to remove excess acids in
the conditions of acidosis of plasma).

- K+ can be secreted as well as reabsorbed from the distal nephron.

Whether net secretion or net reabsorption occurs would depend on the
K+ status of the body. In the conditions of hyperkalemia, net K + secretion
would occur (via the principal cells).

Section 4

Mechanism of formation of concentrated urine

Learning objectives:

1. To understand the concepts of countercurrent mechanisms in the

formation of a concentrated urine.

The human kidney can form concentrated urine. Maximum urine

osmolality is upto 1200 mOsm/L. (or, in other words, 1200 mOsm solutes can be
excreted in just 1 Liter of urine volume.)[Note that: osmolality of plasma ≈ 300
mOsm]

Why is it important to be able to form concentrated urine?

Animals (humans included) living on land do not have a continuous access to

water. Conservation of body water, by excreting a concentrated urine, is an
important adaptation in this context.

Concentrated urine, or hypertonic urine, excretes the solutes but conserves water
in the body. Just adequate amount of water will dissolve the solutes to be
excreted in urine.

Video link ~ Physiological benefit of concentrated urine; lot of body water

is saved

• Two important determinants in the formation of a concentrated urine are:

(1) Hyperosmolarity of the medullary interstitum, and

(2) Role of ADH.

Video link ~ Conceptual basis of countercurrent mechanism; ADH can make

the urineconcentrated when there is high osmolarity outside the tubules.

(1) Hyperosmolarity of medullary interstitium:

Let us recall:

Kidney has two types of nephrons:

(i) Cortical nephrons (85%)

(ii) Juxtamedullary nephrons (15%) – with long loops

With long loops, it is possible to add more and more solutes into the interstitium
and create a hypertonic environment in medulla. Hence, formation of
concentrated urine is the function of juxtamedullary nephrons.

* Diagrammatic
representation of cortical
and juxtamedullary
nephrons.15% of the
nephrons are
juxtamedullary. Their
glomeruli are incortex,
just adjacent to medulla.

The juxtamedullary
nephrons have long loops
MEDULLA of Henle that almost
reachthe renal papilla.

Medullary interstitium is part

CORTEX
of the
medulla outside these long
loops.
First step in the formation of concentrated urine is creating “hyperosmolarity in
the medullary interstitium”. Solutes areare
Solutes conserved
temporarilyand accumulated in the
medullary interstitium to create a held in the medullaryWhen this happens, the
hyperosmolarity.
interstitium, making
tubular fluids in collecting duct then can achieve osmotic equilibrium with the
thisregion hypertonic.
medullary fluid; that is, even the tubular fluids can achieve the same
hyperosmolarity. Hyperosmolar tubular fluids will eventually form hyperosmolar
(concentrated) urine.

Hyperosmolarity of the medullary interstitium is:

- Established by “countercurrent multiplication” and urea recycling,

and

- Maintained by “countercurrent exchange” in the vasa recta.

The long loops of Henle (of juxtamedullary nephrons) are the ‘countercurrent
multipliers’;

Vasa recta (blood vessels along the loops) are the ‘countercurrent exchangers’.

Video link ~ Na+ & urea used to create hyperosmolarity in interstitium;

one is required by thebody, the other is to be excreted out.

• Countercurrent multiplication in the loop of Henle:

- The countercurrent flow is an important aspect in formation of

concentrated urine.
[Fig: The diagram shows the movement of tubular fluids. Fluid goes down in the descending
limb of loop of Henle, then travels in the opposite direction in the ascending limb. Then, it
again travels in the opposite direction in the collecting duct. This type of flow is called
“countercurrent flow” of tubular fluid.]

- The countercurrent flow of fluid allows the reabsorbed solutes to

accumulate in one region. The fluid flows in opposite directions; it
helps to increase the osmolarity of the medullary interstitium.
➢ Countercurrent multiplication:
- The events start in the THICK ASCENDING LIMB (TAL) of loop of
Henle.
- Thick ascending limb (TAL) of loop of Henle is impermeable to
water.

The diagram shows

thick ascending limb of
200 loop of Henle. This p art
400 mOs is impermeable to
Thick
mOs water.
40 ascending
NKC
limb It contains the NKCC
Medullar transporter (Na+-K+-Cl -
y cotransporter). Na+, K+,
interstiti and Cl- are transport ed
from the tubular lum en
into the interstitium .

- The NKCC transporter causes solutes – 1 Na+: 1 K+: 2 Cl- - to be

transported into the interstitium.
- Since thick ascending limb is impermeable to water, water was left
behind in the tubular fluid and solutes (Na+, K+, Cl-) are transported
out into the interstitium. Hence, tubular fluid in the thick ascending
 limb becomes hypotonic (200 mOsm) and interstitium begins to
become hypertonic (400 mOsm).
- The descending limb will now go into osmotic equilibrium with the
medullary interstitium, by movement of water from the descending
limb into the interstitium. Hence, osmolarity of the tubular fluids in
the descending limb will also increase (400 mOsm).
- Now, new filtrate (with solutes) comes from the glomerulus. The
hypertonic fluid in the descending limb will be pushed forward into
the ascending limb. Thick ascending limb will again reabsorb solutes
from it into the interstitium; medullary interstitium osmolarity will
further increase (600 mOsm).
- Again the descending limb will try to equilibrate with the medullary
interstitium (600 mOsm). Again, new filtrate will be added from the
glomerular filtration. The fluid in the descending limb will move
forward into the ascending limb; thick ascending limb will reabsorb
more solutes from it, and so on.
- Maximum osmolarity achievable in the medullary interstitium is
about 1200 mOsm/L (roughly 4 times the plasma osmolarity). At the
very bend of the loop of Henle, the interstitial osmolarity is about
1200 mOsm/L. Hence, tubular fluids can also achieve maximum
osmolarity up to 1200 mOsm/L. Thus, maximum concentration of
urine can be up to 1200 mOsm/L.
➢ Role of urea:
As descending limb of loop of Henle tries to achive osmotic
equilibrium with medullary interstitium, it does so by causing water
movement from the descending limb into the interstitium (osmosis).
This will increase the osmolarity of descending limb fluid, but since
water is going in the interstitium, osmolarity of interstitium may
decrease. This is where urea plays its part in maintaining the
hyperosmolarity of the interstitium.
Urea travels in the tubular fluids but is not absorbed from the
proximal naphron.
 Urea is absorbed from inner medullary collecting duct. It enters the
medullary interstitium and maintains hyperosmolarity there.
➢ Urea recycling: From the interstitium, urea will again enter the
tubular fluids (ascending limb), will reach the collecting duct
and then again reabsorbed into the interstitium. As urea was
not reabsorbed in earlier part of the nephron, it gets
concentrated as it reaches the collecting duct. It gets further
concentrated due to the recycling. This helps in the body
economy. Urea is a waste product. It has to be excreted. But
before it is excreted, it gets concentrated and imparts
hyperosmolarity to the interstitium, thus helping in formation
of concentrated urine. [Urea has to be excreted in urine. If it
was not recycled and concentrated, and was straightaway
excreted in urine, then its excretion would require a lot of
water. Thus, excess water would be excreted in urine.]
▪ urea recycling contributes about 40-50% to the total
osmolarity of interstitium. From interstitium it is transported
back to nephron, and again reabsorbed.
➢ “Countercurrent exchange”: Role of vasa recta
[Fig: The diagram shows the loop of Henle with the vasa recta. (recta = straight). The vasa
recta are straight long blood vessels with two limbs and U-shaped bend. The blood flow in
vasa recta is in OPPOSITE direction to that of the flow of tubular fluids in the loop of
Henle.]

- Blood flow in the vasa recta is in opposite direction to that of the

flow of tubular fluids in the loop of Henle – the “countercurrent
flow”.
- Blood flows down in the descending limb of the vasa recta; this
descending limb is adjacent to the ascending limb of loop of Henle.
And then, blood flows up in the ascending limb of vasa recta; this
limb is adjacent to the descending limb of loop of Henle.
- Due to the long length of the vasa recta, blood flow in them is
sluggish. Due to the slow blood flow here, the solutes reabsorbed
from the loop of Henle are not washed off from the interstitium.
Sluggish blood flow helps to maintain the hyperosmolarity of the
medullary interstitium.
- Exchanger mechanism:
o As blood flows down in the descending limb, it takes in the
solutes that have entered the interstitium and gives out water.
Thus, as the blood flows down, its osmolarity goes on
increasing. At the very tip of vasa recta (at the U-bend),
osmolarity will be maximum – 1200 mOsm/L.
o As the blood flows back upward in the ascending limb, it gives
out the solutes to the interstitium and takes the water back
into the blood vessel. Thus, the osmolarity of blood will go on
decreasing in the ascending limb.
o Due to this type of exchange (of solutes), the vasa recta
maintain the solutes in the interstitium, thus helping the
hyperosmolarity of the medullary interstitium.
• In short, vasa recta do not contribute to the hyperosmolarity of the
medullary interstitium; it only prevents the dissipation of the
hyperosmolarity (only helps to maintain the hyperosmolarity). Sluggish
blood flow is an important factor in maintaining the interstitial
hyperosmolarity.
If blood flow rate increases in vasa recta, solutes will be washed away
from medullary interstitium. If solutes do not remain in medullary
interstitium, urine can not be made hypertonic.

(2) Role of ADH: (In formation of concentrated urine)

➢ Tubular fluids leave the loop of Henle and reach the distal convoluted
tubule. Since the thick ascending limb of loop of Henle was impermeable to
water, tubular fluid that leaves the thick ascending limb and enters DCT has
more water (hypotonic).
➢ ADH removes water from the tubular fluid in the late distal tubule and
collecting duct until its osmolarity equals that of surrounding interstitial
fluid. Final urine osmolarity is determined by this ADH action.

• Maximal hypertonic urine (or maximum urine concentration) can be 1200

mOsm/L (or 4 times the plasma osmolality).
• Most hypotonic (or dilute)urine may be 50 mOsm/L (or 1/6th of the plasma
osmolality).
A dilute urine means more water relative to solutes (hypotonic urine).
Dilute urine excretion occurs when water load in plasma has increased.
Plasma becomes hypotonic. It is sensed by hypothalamus, and secretion of
ADH is stopped. Diuresis occurs and water is lost in the urine.

• A young healthy adult has to excrete at least 600 mOsm of solutes every
day. Since maximum concentrating ability of kidney is 1200 mOsm/L, to
remove 600 mOsm solutes at least ½ L urine will have to be formed. Thus,
 obligatory urine output would be ½ liter per day (to eliminate 600 mOsm
with most concentrated urine).
• And, with most hypotonic urine, maximal urine output can be up to 20
L/day.

Section 5

Urinary bladder, micturition, and cystometrogram

Learning objectives:

1. To learn the functional anatomy of urinary bladder and to understand the

process of micturition.
2. To learn various abnormalities of bladder function

➢ Urine is an excretory product formed every minute. However, it will be

very inconvenient to excrete it every now and then. Hence, urine is first
collected in the urinary bladder. Then, with a suitable time and place
certain amount of urine is excreted out. Micturition is the process of
voiding of urine from the bladder.

➢ Urine collected in the urinary bladder is excreted out via urethra.

➢ Daily urine excretion ≈ 1-1.5 L.

• Functional anatomy of urinary bladder:

- Urinary bladder wall consists of:

1. Stretch receptors – They convey the stretch of the bladder wall

due to filling of urine,

2. Detrusor muscle – Contraction of this muscle causes emptying of

the bladder.

- There are two sphincters at the base; these sphincters regulate the
flow of urine into the urethra:

(1) Internal urethral sphincter – It is a smooth muscle; under

autonomic control.

(2) External urethral sphincter – It is a striated muscle. Under

voluntary control, it is innervated by pudendal nerve. Voluntary
control of the process of urination is provided by external
sphincter.
 [Fig: Diagrammatic representation of the neural components involved in the process of
micturition. Refer to text for details.]

• Innervation of the bladder -

- Parasympathetic nerves that control the bladder: S2,3,4. (nervi
erigentes or pelvic nerves; control detrusor muscle and
internal urethral sphincter). These nerves form a reflex arc
from the bladder wall to the spinal cord and back to bladder.
- Sympathetic nerves: hypogastric nerves; convey pain sensation
from the bladder.
- Pudendal nerve: somatic nerve; controls external urethral
sphincter (a striated muscle). Neurons are located in the
“Onuf’s nucleus” in the spinal cord.
• Micturition centers in CNS:
1. Spinal cord: S2,3,4. It is the center for micturition reflex.
Afferent nerves arising from the bladder wall convey the
signals about the stretch of the bladder wall (filling of the
bladder) to this spinal cord center. The efferents from
spinal cord will then reach the bladder; they will cause
detrusor contraction and relaxation of the internal urethral
sphincter.
Also, when the signals about bladder stretch reach the
spinal cord (S2,3,4), they are conveyed to the brain stem
center.
2. Brain stem (pontine) center: called “Barrington’s center”;
it is an integrating center for the process of micturition. It
receives signals from the bladder (regarding the bladder
wall stretch) and conveys them to the cortex.
This center consists of both facilitatory and inhibitory
groups of neurons which either facilitate or inhibit the
sacral center for micturition; thus exerting control over the
micturition reflex.
 3. Voluntary center (cortex): situated in paracentral lobule in
frontal lobe. It is mainly an inhibitory center. It controls the
external urethral sphincter. When micturition is desirable,
the cortical center will lift its inhibition of the external
urethral sphincter. Relaxation of the external sphincter can
then initiate the micturition.
(Micturition reflex begins at 5th month of I.U. life when urine secretion
starts; voluntary control of micturition does not appear until the age of 2 ½
to 3 years.)
➢ Micturition reflex and the process of micturition:
- As the urine begins to be filled in the bladder, the bladder wall
begins to stretch.
- When about 100-150 mL is filled in the bladder, the stretch
receptors in the bladder wall begin to convey the impulses,
from the bladder, to the spinal cord (S2,3,4 segments).
- From the spinal cord segments, the signals are then
transmitted toward brain in the DORSAL COLUMNS of the
spinal cord. The sensations will reach the sensory cortex
(parietal lobe); sensations reach the consciousness.
- As the bladder continues to get filled further, the number of
impulses from bladder to spinal cord and from there to the
higher brain will gradually increase.
- If micturition is not desired at this stage, the frontal lobe
voluntary center will keep the brain stem center inhibited.
Brain stem center will keep the reflex arc from the bladder
inhibited.
- If and when micturition is desirable (with suitable time and
place) – The voluntary inhibition by the frontal lobe center will
be lifted. Now, the brain stem facilitatory center will initiate
the signals to facilitate the reflex arc from the bladder. The
process of micturition can begin.
▪ Micturition reflex is a “self-regenerative process”. That is, it occurs as a
“positive feedback” cycle. It starts as a weak signal, and gradually becomes
stronger and stronger by positive feedback.
▪ Signals from bladder wall reach spinal cord (sacral segments). Via the
efferents of the reflex arc, signals run back to the bladder.
▪ First event in the micturition reflex is detrusor contraction. The internal
urethral sphincter will relax. A series of events will be initiated.
▪ First few drops of urine enter posterior urethra. Dilatation of the urethra
will cause signals to arise from there to again go back to the spinal cord.
Detrusor contraction and relaxation of the external urethral sphincter will
follow.
▪ Urine will continue to flow down the urethra. Bladder contractions will
become stronger and stronger (positive feedback process), till the void
occurs.
▪ Toward the end of the micturition process, the reflexes abet; micturition
process becomes weaker and stops.
▪ About 50 mL urine is left in the bladder. It is called “residual urine”.

• NOTE:
- 100-150 mL urine in the bladder: first sensation of filling of
bladder
- 150 – 250 mL in the bladder: first desire/urge to void;
- 300-400 mL in bladder: initiates reflex contraction;
- 450 mL in bladder: urgency for micturition;
- 750 mL in bladder: painful urgency for micturition.

• Cystometrogram:
- It is a graphic depiction of the pressure-volume relationship in
the bladder. (increase the bladder pressure with increasing
urine volume in bladder; cyst = bladder)
 Pressure
in II
bladder
wall

(cm H2O)

Ib
Ia

100 200 300 400 450

Urine volume (mL) in bladder

The cystometrogram shows 3 phases:

1. Phase Ia – Volume in bladder upto 100 mL.
As the urine is filled in bladder, pressure in the bladder wall increases
gradually.
2. Phase Ib – [Laplace’s law]
The urinary bladder is a hollow sphere. Hence, it obeys Laplace’s law.

P = 2T/R; where P – pressure in the sphere, T – tension in the wall, and R –

radius of the sphere.
It indicates that the pressure in a hollow viscus is directly proportional to
the wall tension and inversely proportional to the radius.
From 100 mL to 400 mL urine getting filled in the bladder –
Tension (T) in the wall increases, but radius (R) of the bladder also
increases. [Both numerator & denominator increase proportionately.]
Hence, pressure (P) in the bladder wall remains almost the same. As the
 pressure in the bladder wall does not increase much, signals arising from
the bladder wall are not strong.
3. Phase II -
As about 400-450 mL urine is filled in the bladder, wall tension (T) increases
further but radius (R) cannot increase any further. (Denominator remains
constant but numerator increases). Hence, the pressure (P) in the bladder
wall will increase steeply now. Strong signals will be sent from the bladder
wall to the spinal cord and from there to the higher centers. There will be
urgency for micturition at this stage.

Applied physiology:

• Types of bladder: (effects of lesions at various levels)

1. Atonic bladder:
▪ Deafferentation; or lesion of the afferent nerves from bladder.
▪ Reflex contractions of bladder are abolished
▪ May be due to tabes dorsalis in which dorsal root nerve fibers
from bladder damaged – tabetic bladder.
2. De-centralized bladder:
▪ When both the afferents and efferents of bladder are damaged.
▪ Bladder is flaccid and distended; may become active gradually,
expels dribbles of urine
▪ May be caused by tumors of cauda equina or filum terminale.
3. Overflow incontinence:
▪ If the spinal cord is damaged above sacral segments, leaving reflex
pathway intact. Initially, “spinal shock” condition causes
suppression of reflexes; results in loss of bladder tone.
▪ Bladder becomes overfilled and exhibits sporadic voiding.
4. Automatic bladder:
▪ As the spinal shock wears off, micturition reflex returns but
without voluntary control. Periodic but unannounced emptying of
bladder.
5. Spastic neurogenic bladder or uninhibited bladder:
 ▪ Partial damage to spinal cord that interrupts inhibitory influences
from higher centers.
▪ Also, if there is a lesion in the brain between voluntary control
center (frontal lobe) and pontine center. Inhibition of the bladder
emptying is lost.
▪ Bladder capacity reduced and reflex hyperactivity occurs.
▪ Onset of micturition cannot be controlled voluntarily once the
reflexes are initiated; voluntary mid-stream holding not possible.

————————————————————————————————————

Section 6

ACID-BASE BALANCE

Introduction/Learning objectives:

1. Normal functioning of cells is possible only when pH of body fluids is kept

normal. Especially, intracellular pH has to be kept constant for the
enzymes to function normally.
2. Kidney is an important component of the buffer systems in body. Kidney
diseases may cause derangement of acid-base balance.
This section deals with various buffer system mechanisms in the context
of acid-base balance and related disorders.

~ Acid is defined as any substance that adds H+ to the body fluids, whereas alkali
is defined as a substance that removes H+ from the body fluids.
CO2 derived from aerobic metabolism is termed volatile acid, since it has the
potential to generate H+ after combining with H2O.

{CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3-}

The Henderson-Hasselbalch equation is used to quantitate how changes in CO2

and HCO3- affect pH.

pH = pKa + log [HCO3-/(0.03 × PCO2)]

{pKa is the pH at which the acid is half dissociated from its conjugate base.}

The two components of this equation are:– CO2 (acid) and HCO -3(alkali).

Excess addition of H+ to the body fluids is called acidosis; excess removal H+ from
the body fluids is referred to as alkalosis.

The defenses against changes in the H+ concentration:

The 3 defense lines that regulate the H+ concentration in the body fluids
and prevent acidosis or alkalosis ~ (1) The chemical buffer system of the body
fluids, (2) The respiratory system, and (3) The kidneys. {Note that: These defenses
would react to a change in pH in the given order.}

(1) The chemical buffer system:

- The first line of defense; these buffers react within seconds.
- The 3 chemical buffers are bicarbonate, phosphate, and
intracellular proteins.
(a) The bicarbonate buffer system – (components ~ HCO3- &
H2CO3)
o Its pK is 6.1 {pK of a buffer system is the pH at or
around which the buffer system is most effective.}
Since the pK is 6.1, and pH of ECF is 7.4, the ratio
of [HCO3-]/[H2CO3] should be maintained at 20 for
a given pH 7.4 according to Henderson-
Hasselbalch equation.
 o It is the most powerful buffer in the ECF.
Increasing plasma HCO3- increases the plasma pH.
o It is an important and effective buffer system
because the two elements of this system – HCO3 -
& CO2 – are regulated precisely by the kidneys and
the respiratory system.
(b) The phosphate buffer system – (components ~ HPO 4-- &
H2PO4-)
o Its pK is 6.8. {pH of ECF is 7.4 and intracellular pH
is 7.2.} The ratio of [HPO4--]/[H 2PO4-] should be
maintained at 4, for a given pH of 7.4.
o It has a major role in buffering renal tubular fluid
and intracellular fluid.
(c) Proteins –
o Among the most plentiful buffers in the body;
they are the most important intracellular buffers.
Reason: proteins are in high concentrations within
the cells and pKs of many protein buffers are fairly
close to 7.2.

o About 60-70% of the total chemical buffering of

the body fluids is inside the cells, and most of it is
by the proteins.

• Hemoglobin as a buffer:
- Though present inside the red cells, Hb is an ECF buffer; its
buffering mechanisms pertain to the ECF (plasma).
- Deoxy-Hb is a good acceptor of H+. Thus, in tissues, when Hb
delivers O2, it takes up and buffers H+.
- Oxyhemoglobin is a donor of H+. Thus, in lungs, when O2 binds
with Hb, H+ is given up by Hb.
(2) The respiratory system in acid-base regulation: (A “physiologic” buffer
system)
- The second line of defense; it acts within a 3 to 12 minutes to
eliminate CO2 and thus H+ ions from the body. Increased CO2
stimulates ventilation via formation of H +; H+ stimulates the
respiratory center and the resultant increase in ventilatory
drive washes-off the CO2 and H+. A decrease in CO2 and H+ will
have an opposite effect, that is, it decreases the ventilatory
drive.
- When ventilation is doubled, pH increases by 0.45, and when
ventilation is halved, pH decreases by 0.23.
- It is more effective in a condition of decreased pH as compared
to that of an equivalent increase in pH.
- Impairment of lung function may lead to “respiratory acidosis”
(increased CO2 & H+); excess ventilatory drive may lead to
“respiratory alkalosis”.

Video link ~ Respiratory ‘buffer’

system; the “Physiologic” buffer

(3) Role of kidneys in acid-base balance:

- Third line of defense; it acts slowly over hours-to-days.
However, the strongest acid-base regulatory system.
- Kidneys regulate the H+ concentration by 3 basic mechanisms –
(a) Reabsorption of the filtered bicarbonate, (b) Secretion of H+
into the tubules and its excretion, and (c)Generation of new
bicarbonate
(a) Plasma HCO3- is 24 meq/L, and GFR is 180 L/day. Thus, (24 ×
180 =) 4320 meq of HCO3- is filtered every day by kidneys.
About 80% of it is reabsorbed from the PCT; 10% in the TAL,
 and remaining in the distal nephron. Thus, kidneys conserve
the primary buffer system of the body.
(b) The HCO3- can be reabsorbed only after it reacts with H+ (H+ +
HCO - → H CO → CO + H O, is necessary for movement
3 2 3 2 2
across tubular cells). Thus, 4320 meq of H+ will have to be
secreted by tubules. Plus, 80 meq of non-volatile acids are
produced daily from the metabolism of proteins. Hence, (4320
+ 80 =) 4400 meq of H+ ions are secreted every day by renal
tubules, almost 80-90% of this occurs in the PCT. H+ and HCO3-
are “titrated” against each other in the tubules. In acidosis,
excess H+ will be excreted into urine; in alkalosis, excess HCO3-
is excreted. Normally, about 50-100 meq of H+ (equivalent to
the non-volatile acids) is exreted in urine; urine is normally
acidic.
[Removal of an H+ ion is the biochemical equivalent of addition
of a bicarbonate ion. Thus, H+ excretion is coupled with
generation of HCO3- in the renal tubules, to correct acidosis.]
(c) Excess H+ combines with urinary buffers ~ phosphate and
ammonia (NH3). These two buffers also generate new HCO3-
that can be added to blood in conditions of acidosis.
- Ammonia is synthesized from glutamine in renal tubular
cells; one molecule of glutamine produces two
molecules of ammonia and two HCO3- are added to ECF.
- Non-ionic diffusion: NH3 secreted by tubules combine
with H+ in the lumen to form NH4+; NH4+ now cannot
diffuse back into the tubular cell. Thus, NH4+ is trapped
in the lumen and excreted in urine, eliminating the H+.
- NH3/NH4+ is the buffer for chronic respiratory acidosis.
 - H+ eliminated by phosphate buffer is called “titratable
acid”. The ratio of titratable acid to ammonia-buffered
acid is about 1: 2.5.

[Fig: Ammonia buffer acts by non-ionic diffusion or diffusion trapping. Remember: For any
substance, non-ionic form is readily diffusible; ionic form is less diffusible. NH3 is generated
by renal tubular cell. It diffuses into the lumen. It binds with the H + in tubular fluids; NH4+ is
formed now which is ionic form. It can not diffuse back into the renal tubular cell (it is
“trapped” in the lumen). NH4+ will be excreted into urine, thereby eliminating the H+.]

• Titratable acidity: In a condition of acidosis, there will be urinary

acidification. Acid excretion in the urine is due to the action of urinary
buffers in the tubules. The urine sample is collected and is titrated against
NaOH, to bring the pH back to 7.4 (that is, the normal pH of blood). The
amount of alkali (NaOH) required in this reaction gives the amount of
titratable acids eliminated in the urine. It is mostly the acids buffered by
phosphate; creatinine, uric acid may also contribute. H+ combined with
ammonia is NOT included in titratable acidity. Reason: Of the two urinary
buffers, ammonia has a pK of about 9.2. It means, in the given titration
(from acidic pH to 7.4) ammonia buffer is not active. Thus, titratable acidity
can be said to be phosphate-buffered acid in urine.
 • H+ secreted by the proximal nephron is combined with HCO3- and thus is
utilized for the purpose of HCO3- reabsorption. It means, this H+ does not
contribute in urinary excretion of acid. The major site for urine acidification
is the DCT and collecting duct. The H+ secretion here is against the
concentration gradient. It can create a gradient for H + of about 1000: 1
between the tubular fluids and the plasma. This is the maximal H+ secreted;
it makes the urine pH about 4.5. This is called “limiting pH" of the tubular
fluids. And, the urine can be acidic up to this pH.

Clinical application: Acid-base disorders

• pH alteration leads to two types of conditions:- (a) Acidosis ~ when pH of

ECF decreases, and (b) alkalosis ~ when pH of ECF increases.
(Recall: The two components of the Henderson-Hasselbalch equation ~ CO2
and HCO3-. CO2is considered a volatile acid; it forms H+ in body fluids. HCO3-
is an alkali.)
Acidosis or alkalosis is of two types: Metabolic or respiratory.
▪ Acidosis results if HCO3- is depleted from ECF or CO 2is
accumulated. (a) When metabolic derangements lead to a loss
of HCO3-, it is termed metabolic acidosis. (b) If respiratory
dysfunction has caused accumulation of CO2, it is termed
respiratory acidosis.
▪ Alkalosis results from either accumulation of HCO3- (alkali) or
wash out of CO2 (acid). Thus, it could be metabolic alkalosis
(when metabolic abnormalities lead to accumulation of HCO 3-),
or respiratory alkalosis (when respiratory disorders cause a
CO2 wash out).

Compensation:

▪ Correction of acidosis or alkalosis by the buffer systems

▪ If it is a metabolic acidosis/alkalosis, compensation is done by
respiratory system – by adjusting the CO2 levels
 ▪ If it is a respiratory acidosis/alkalosis, compensation is done by
kidneys – by adjusting the HCO3- levels.

Example:- Hyperventilation —> CO2 (and hence H+) is washed out —> results in
alkalosis. Kidneys will then increase the excretion of HCO3-, thereby correcting the
pH.

Note: Even after full compensation, pH does not exactly return to normal; some
error will still exist. Hence, diagnosis of acidosis/alkalosis can be made even after
correction, as there is some residual error that is indicative of the original pH
disturbance.