THE GLOMERULUS AND GLOMERULAR FILTRATION RATE

The glomerulus plural glomeruli, is a network of capillaries known as a tuft, located at the
beginning of a nephron in the kidney. The tuft is structurally supported by
intraglomerular mesangial cells. The blood is filtered across the capillary walls of this tuft
through the glomerular filtration barrier, which yields its filtrate of water and soluble substances
to a cup-like sac known as Bowman's capsule. The filtrate then enters the renal tubule, of the
nephron. The glomerulus receives its blood supply from an afferent arteriole of the renal arterial
circulation. Unlike most capillary beds, the glomerular capillaries exit into efferent
arterioles rather than venules. The resistance of the efferent arterioles causes sufficient
hydrostatic pressure within the glomerulus to provide the force for ultrafiltration.

The glomerulus and its surrounding Bowman's capsule constitute a renal corpuscle, the basic
filtration unit of the kidney. The rate, at which blood is filtered through all of the glomeruli, and
thus the measure of the overall renal function, is the glomerular filtration rate (GFR).

The glomerulus has a glomerular basement membrane (GBM) consisting mainly of laminins,
type IV collagen, agrin and nidogen, which are synthesized and secreted by both endothelial cells
and podocytes: thus the GBM is sandwiched between the glomerular capillaries and the
podocytes. The GBM is 250–400 nm in thickness, which is thicker than basement membranes of
other tissue. It is a barrier to blood proteins such as albumin and globulin.

The part of the podocyte in contact with the GBM is called a podocyte foot process or pedicle;
there are gaps between the foot processes through which the filtrate flows into Bowman's space
of the capsule. The space between adjacent podocyte foot processes is spanned by slit
diaphragms consisting of a mat of proteins, including podocin and nephrin. In addition, foot
processes have a negatively charged coat (glycocalyx) that repels negatively charged molecules
such as serum albumin.

INTRAGLOMERULAR MESANGIAL CELLS

The space between the capillaries of a glomerulus is occupied by intraglomerular mesangial

cells. They are not part of the filtration barrier but are specialized pericytes that participate in the
regulation of the filtration rate by contracting or expanding: they contain actin and myosin
filaments to accomplish this. Some mesangial cells are in physical contact with capillaries, others
are in physical contact with podocytes. There is two-way chemical cross talk among the
mesangial cells, the capillaries, and the podocytes to fine-tune the GFR.

HOW GLOMERULAR FILTRATION WORKS

The first step in making urine is to separate the liquid part of your blood (plasma), which
contains all the dissolved solutes, from your blood cells. Each nephron in your kidneys has a
microscopic filter, called a glomerulus that is constantly filtering your blood.

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Blood that is about to be filtered enters a glomerulus, which is a tuft of blood capillaries (the
smallest of blood vessels). The glomerulus is nestled inside a cup-like sac located at the end of
each nephron, called a glomerular capsule. Glomerular capillaries have small pores in their walls,
just like a very fine mesh sieve. Most capillary beds are sandwiched between arterioles and
venules (the small vessels delivering blood too and collecting blood from capillary beds), and the
hydrostatic pressure drops as blood travels through the capillary bed into the venules and veins.
The glomerulus, on the other hand, is sandwiched between two arterioles - afferent arterioles
deliver blood to the glomerulus, while efferent arterioles carry it away. Constriction of efferent
arterioles as blood exits the glomerulus provides resistance to blood flow, preventing a pressure
drop, which could not be achieved if blood were to flow into venules, which do not really
constrict. The two arterioles change in size to increase or decrease blood pressure in the
glomerulus. In addition, efferent arterioles are smaller in diameter than afferent arterioles. As a
result, pressurized blood enters the glomerulus through a relatively wide tube, but is forced to
exit through a narrower tube. Together, these unique features plus the fact that your heart is
supplying your kidneys with over a liter of blood per minute (around 20% of its output) maintain
a high glomerular capillary pressure and the filtration function of the kidney, regardless of
fluctuations in blood flow. For example, the sympathetic nervous system can stimulate the
efferent arteriole to constrict during exercise when blood flow to the kidney is reduced.

CHARACTERISTICS OF THE GLOMERULAR CAPILLARY WALL

The physical characteristics of the glomerular capillary wall determine what is filtered and how
much is filtered into the glomerular capsule. Working from the inside out, the capillary walls are
made up of three layers:

Endothelium - this has relatively large pores (70-100 nanometers in diameter), which solutes,
plasma proteins and fluid can pass through, but not blood cells.

Basement membrane - this membrane is also made up of three layers, and is fused to the
endothelial layer. Its job is to prevent plasma proteins from being filtered out of the bloodstream.

Epithelium - this layer consists of specialized cells called podocytes. These cells are attached to
the basement membrane by foot processes (pedicels). They wrap around the capillaries, but leave
slits between them, known as filtration slits. A thin diaphragm between the slits acts as a final
filtration barrier before the fluid enters the glomerular space.

The glomerular capillary wall consisting of the endothelium, basement membrane, and
epithelium Together the glomerulus and glomerular capsule filtering unit are known as a renal
corpuscle.

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Figure 2: Glomerular capillary wall, consisting principally of a fenestrated endothelium, a
basement membrane, and epithelial foot processes. The foot processes form filtration slits
spanned by slit diaphragms. Also shown is the endothelial cell coat, or glycocalyx. Some
approximate dimensions are minimum diameter of fenestra, 30 nm; GBM thickness, 200–400 nm
(depending on species); width of filtration slit, 40 nm. The glycocalyx thickness is uncertain.
Figure is not drawn to scale.

In addition to the unique glomerular capillary bed, the kidneys have other specialized capillaries,
called peritubular capillaries that are tiny blood vessels that run parallel to and surround the
proximal and distal tubules of the nephron, as well as the loop of Henle, where they are known as
the vasa recta. The vasa recta are important for countercurrent exchange, the process that
concentrates urine.

THE GLOMERULAR FILTRATION RATE (GFR)

The rate at which kidneys filter blood is called the glomerular filtration rate. The main driving
force for the filtering process or outward pressure is the blood pressure as it enters the
glomerulus. This is counteracted to some extent by inward pressure due to the hydrostatic
pressure of the fluid within the urinary space, and the pressure generated by the proteins left in
the capillaries that tend to pull water back into the circulatory system (colloidal osmotic
pressure). The net filtration pressure is the outward pressure minus the inward pressure.

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The figure: illustrating the forces that determine the filtration rate. The pressure in the glomerular
capillaries, PGC, favors filtration. Opposing filtration is the osmotic pressure due to the blood
proteins (ΠGC) and the hydrostatic pressure in Bowman's space (PBS). The net glomerular
filtration pressure is the sum of these forces.

Hydrostatic Pressure Changes

Many factors can change GFR through changes in hydrostatic pressure, in terms of the flow of
blood to the glomerulus. GFR is most sensitive to hydrostatic pressure changes within the
glomerulus. A notable body-wide example is blood volume.

Due to Starling’s law of the heart, increased blood volume will increase blood pressure
throughout the body. The increased blood volume with its higher blood pressure will go into the
afferent arteriole and into the glomerulus, resulting in increased GFR. Conversely, those with
low blood volume due to dehydration will have a decreased GFR.

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Pressure changes within the afferent and efferent arterioles that go into and out of the glomerulus
itself will also impact GFR. Vasodilation in the afferent arteriole and vasconstriction in the
efferent arteriole will increase blood flow (and hydrostatic pressure) in the glomerulus and will
increase GFR. Conversely, vasoconstriction in the afferent arteriole and vasodilation in the
efferent arteriole will decrease GFR.

The Bowman’s capsule space exerts hydrostatic pressure of its own that pushes against the
glomerulus. Increased Bowman’s capsule hydrostatic pressure will decrease GFR, while
decreased Bowman’s capsule hydrostatic pressure will increase GFR.

An example of this is a ureter obstruction to the flow of urine that gradually causes a fluid
buildup within the nephrons. An obstruction will increase the Bowman’s capsule hydrostatic
pressure and will consequently decrease GFR.

Osmotic Pressure Changes

Osmotic pressure is the force exerted by proteins and works against filtration because the
proteins draw water in. Increased osmotic pressure in the glomerulus is due to increased serum
albumin in the bloodstream and decreases GFR, and vice versa.

Under normal conditions, albumins cannot be filtered into the Bowman’s capsule, so the osmotic
pressure in the Bowman’s space is generally not present, and is removed from the GFR equation.
In certain kidney diseases, the basement membrane may be damaged (becoming leaky to
proteins), which results in decreased GFR due to the increased Bowman’s capsule osmotic
pressure.

The rate at which plasma is filtered (measured in ml/min) is known as the glomerular filtration
rate (GFR). Filtration is a non-specific process of bulk flow: water and small molecular weight
substance move from the glomerular capillaries, across the filtration membrane, and enter
Bowman’s space. Roughly 20% of the total volume of plasma flowing through the glomerular
capillaries is filtered. Since filtration involves bulk flow, the concentration of a substance in
Bowman’s space is the same as its concentration in the plasma.

Filtration is possible because of the high pressure in the glomerular capillaries (PGC). The
glomerular capillaries are unique in that they lie between two arterioles, the afferent arteriole and
the efferent arteriole. Due to the added resistance of the efferent arteriole, P GC is higher than
pressure in a typical capillary.

The glomerular capillary wall is a living ultrafiltration membrane. It permits water and small
solutes to pass readily into Bowman’s space, while normally rejecting albumin and other large
proteins with great efficiency. The glomerular capillary wall consists of a fenestrated
endothelium, the glomerular basement membrane (GBM), and the interdigitated foot processes

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of epithelial cells (podocytes). The filtration pathway is extracellular; that is, water and filtered
solutes pass through the fenestrae, across the GBM, and through filtration slits bounded by the
foot processes. The filtration slits are spanned by porous slit diaphragms.

DETERMINANTS OF GLOMERULAR FILTERATION RATE (GFR)

1. NET FILTERATION PRESSURE (Pressure favoring filtration – pressure opposing filtration)

2. Permeability (number of pores available for filtration)

3. The surface area available for filtration.

The different membranes of the GCM are negatively charged and protein is also negatively
charged, proteins are not normally filtered by the glomerulus as they are repelled by the charges
of the GCM. However, positively charged substances are easily filtered by the glomerulus since
opposite charges attract. Apart from charges, the molecular weight of substances also plays a role
in their filtration at the glomerulus. The pores of the glomerular membrane is about 8 nanometers
(80 angstroms), as a result of the size of the pores substances with sizes higher than that of the
glomerular pore are not filtered. However in the case of plasma protein, even though the
molecular diameter of albumin is about 6nm, it is not filtered by the glomerulus due to its
negative charge which results in repulsion. In certain kidney diseases, the negative charges on
the basement membrane are lost even before there are noticeable changes in kidney histology,
as a result of the loss in negative charges on the basement membranes, some of the lower
molecular weight proteins especially albumins are filtered and appear in urine a condition known
as proteinuria.

FACTORS THAT INFLUENCES GLOMERULAR FILTERATION

1-Changes in renal blood flow

2-Changes in glomerular capillary hydrostatic pressure
3-Changes in systemic blood pressure
4-Afferent or efferent arteriolar constriction
5-Changes in hydrostatic pressure in Bowman's capsule
6-Ureteral obstruction
7-Edema of kidney inside tight renal capsule
8-Changes in concentration of plasma proteins: dehydration, hypoproteinemia, etc (minor
factors)
9-Changes in Kf
10-Changes in glomerular capillary permeability
11-Changes in effective filtration surface area

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CONCEPT OF CLEARANCE

The functional state of the kidney can be evaluated using several tests based on the renal
clearance concept. These test measure the rate of glomerular filtration, renal blood flow and
tubular reabsorption or secretion of various substances. A useful way of looking at kidney
function is to think of the kidney as clearing substances from the plasma. When a substance is
excreted in urine, a certain volume of plasma is in effect freed or cleared of that substance; the
renal clearance of a substance is therefore the volume of plasma from which that substance is
completely removed or cleared per unit time. The clearance formula is

Cx = Ux x V

Px

Where x is the substance of interest,

Cx is the clearance of substance x

Ux is the urine concentration of x

V is the urine flow rate (urine volume x time of collection).

GLOMERULAR FILTERATION RATE (GFR)

An important measurement of the evalution of the kidney function is the GFR. This is the rate at
which plasma is filtered by the kidney glomeruli. If there was a substance that cleared from
plasma only by glomerular filtration, such substance can be used to measure GFR.

Inulin is an ideal substance to measure GFR. It is a fructose polymer with a molecular weight of
5,000. It is suitable for measuring GFR for the following reasons

It is freely filtered by the glomerulus

It is neither reabsorbed nor secreted

It is not synthesized, destroyed or stored in the kidney.

It is non toxic

Its concentration in urine and plasma can be determined by simple analysis

Since inulin is neither reabsorbed nor secreted, the rate of its excretion is equal to urine inulin.

The inulin filtered per unit time is equal to plasma inulin (PIN ) times GFR. The rate of inulin
excretion is equal to UIN x V.

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The expression UIN x V/ PIN is defined as inulin clearance which equals GFR. The normal value
for inulin clearance corrected for body surface area are 110± 12ml/min for young female adult
and 125± 15 ml/min for young adult men. After age 45 to 50 GFR declines, and it is typically
reduced by 30% to 40% by age 80.

Inulin clearance is the gold standard for measuring GFR and is used whenever highly accurate
measurement of GFR is desired. However inulin has the disadvantage of being an exogenous
marker as it has to be introduced intravenously since it is not synthesized by the body. Also
emptying of the bladder is usually by the use of catheter, since short periods of urine collection is
usually required. These procedures are inconvenient hence it is not used routinely as a renal
function test.

CREATININE CLEARANCE

Creatinine is a waste product of creatine metabolism. It is produced in muscle when creatine is

metabolized to generate energy. It is produced continuously in the body and is excreted in urine.
Long urine collection periods can be used, because creatinine concentrations in plasma are
normally stable and it does not have to be infused, and the use of catheter is not needed. Plasma
and urine creatinine concentrations can be measured using simple colorimetric method. The
endogenous ceatinine clearance is calculated with the same formular for inulin where plasma and
urine inulin is replaced by creatinine. There are some limitations in the use of creatinine in the
determination of GFR as creatinine is secreted and filtered by the kidney, causing a 20% increase
in the numerator, the other drawback is related to errors in measuring plasma creatinine, the
colorimetric method used usually measure other plasma substances such as glucose leading to
20% increase in the denominator of the clearance formula, because the denominator and
numerator are 20% too high, the two errors cancel, so the endogenous creatinine clearance can
be said to be a good approximation of GFR when it is about normal. When GFR in an adult has
been reduced to as low as 20ml/min, because of renal disease the endogenous creatinine
clearance may overestimate GFR by as much as 50%. This results from higher plasma creatinine
value and increase tubular secretion of creatinine. Drugs that inhibit tubular secretion of
creatinine or elevate plasma concentration other than creatinine may cause the endogenous
creatinine clearance to be underestimated.

RENAL BLOOD FLOW

The renal circulation is designed to simultaneously accomplish bulk filtration and reabsorption
and precise selective regulation of the constituents of normal urine. From an enormous blood
flow of about a liter per minute only about 1 ml of urine per minute is formed. The energy
requirement is about 10 per cent of basal oxygen consumption, yet the efficiency of the kidney is
reflected in its low arteriovenous oxygen difference.

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Originally, the renal circulation was quantified by clearance techniques measuring total renal
blood flow.

REGULATION OF RENAL BLOOD FLOW

The kidneys have a combined weight of less than 0.5% of the entire body, yet receive
approximately 20% of cardiac output. While resting, cardiac output may be near 5 l/min, of
which 1 l/min goes to the kidneys. This is primarily necessary to be able to excrete solutes that
cannot be secreted by cells. In addition, it reflects high metabolic activity: the kidneys account
for 7-10 % of total O2 consumption of our body in a resting state.
Renal plasma flow can be measured with the help of para-aminohippurate (PAH). While traces
of PAH may occur in our body by metabolic processes, for the purpose of determining plasma
flow, large quantities are infused intravenously. PAH is freely filtrated at the glomerulus and in
addition actively secreted by the proximal tubule. Almost all of PAH reaching the kidney is
eliminated in a single pass (92%), so that PAH clearance approximates renal plasma flow and,
with the help of the hematocrit, can be used to estimate renal blood flow.
About 90% of the blood leaving the glomeruli perfuses the cortex; only 10%, from a
subpopulation of juxtamedullary glomeruli, go to the medulla via the vasa recta. Because of the
high fluid resistance of these long capillaries, very little of this blood reaches the papilla. This is
important: otherwise, the high osmotic gradient in the medulla would wash out and we would not
be able to concentrate urine. On the other hand, it puts cells in the medulla in a precarious
position: as soon as there is a problem with blood flow, these cells are prone to suffer damage
from lack of oxygen.

More recently, micropuncture and microangiographic techniques have advanced the

understanding of the renal microcirculation. The kidney is not composed of a single
homogeneous circulation but of several distinct microvascular networks. These include the
glomerular microcirculation, the cortical peritubular microcirculation, and the microcirculation
that nourishes and drain the inner and outer medulla. The interlobular arteries taper as they pass
through almost the entire cortex, and each gives rise to about 20 afferent glomerular arterioles
supplying one or more of the 1.5 million glomeruli of the human kidney. The vascular pathways
in the glomerulus change under different physiologic conditions. Hence there is intermittent flow
within glomeruli, which may play a role in regulation of glomerular filtration rate (GFR).
Beyond the glomerulus the efferent arterioles either form dense peritubular capillary plexuses
that nourish the proximal or distal convoluted tubules situated in the cortex or pass into the
medulla (especially from juxtamedullary glomeruli) and divide into bundles of vasa recta that
parallel medullary rays. The slow flow of blood at the vasa recta gives room for exchange of
material between the vasa recta and the medullary interstitium, this is important in keeping the
high osmotic gradient that have been created at the interstitium, this is very important in the
production of concentrated urine.

MEASUREMENT OF RENAL BLOOD FLOW

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The clearance of organic iodides, Diodrast, and para-aminohippurate (PAH) is used to estimate
renal blood flow (RBF) and is based upon application of the Fick principle. These substances, at
low plasma concentrations, are almost totally secreted by the renal tubules and there is no extra
renal metabolism, storage, or production. Accurate utilization of the technique requires normal
renal function and extraction and assumes a renal venous concentration approaching zero. Since
the extraction is probably never complete, the term "effective renal plasma flow" (ERPF) has
been used.

Renal blood flow (RBF) can be determined from measurements of renal plasma flow (RPF) and
blood hematocrit, using the following equation.

Accordingly,

Cpah is calculated by the formula Ui x Qu = (Ai - Vi) x RPF

where
Ui= concentration of indicator in urine (mg/ml)
Qu = urine flow rate (ml/min)
Ai = concentration of indicator in arterial plasma (mg/ml)
Vi = concentration of indicator in venous plasma (mg/ml)
RPF = renal plasma flow rate (ml/min)

UiQu
Rewriting this equation,

RPF = Ai - Vi

Since extraction is assumed to be almost complete in the clinical setting and Ai is kept constant, the
equation for Cpah becomes:
UiQu /Upah x V
RPF = Ai or Ppah

where,
Ppah = Plasma concentration of PAH

of note,
UiQu = excreted load of the indicator (mg/min)

The conversion of renal plasma flow rate to blood flow is achieved by dividing RPF by the plasma
fraction of whole blood as estimated by the hematocrit.
RPF/RBF = 1 - HCT

The complexity of determination of RBF by the Cpah technique and the requirement of normal renal

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function have led to a search for alternative techniques. The radionuclide monitoring techniques also
allow calculation of differential RBF from each kidney, which is often the critical information desired in
the clinical setting.

AUTOREGULATION
one of the most striking characteristics of the renal circulation is the ability of the kidney to
maintain a constant renal blood flow (RBF) and glomerular filtration rate (GFR) as renal
perfusion pressure is altered. The dual regulation of both RBF and GFR is achieved by
proportionate changes in the preglomerular resistance and is believed to be mediated by two
mechanisms, tubuloglomerular feedback (TGF) and the renal myogenic response. TGF involves
a flow-dependent signal that is sensed at the macula densa, and alters tone in the adjacent
segment of the afferent arteriole via a mechanism that remains controversial, but likely involves
adenosine and/or ATP. The myogenic response involves a direct vasoconstriction of the afferent
arteriole when this vessel is presented with an increase in transmural pressure. The current view
is that these two mechanisms act in concert and that their primary role is to stabilize renal
function by preventing pressure-induced fluctuations in RBF, GFR and the delivery of filtrate to
the distal tubule (“distal delivery”).

Regulation of renal blood flow is important to maintaining a stable glomerular filtration rate
(GFR) despite changes in systemic blood pressure (within about 80-180 mmHg). In a mechanism
called

Autoregulation of renal blood flow (RBF) is caused by the myogenic response (MR) and
Tubuloglomerular feedback (TGF). And a third regulatory mechanism that is independent of
TGF but slower than MR. The underlying cause of the third mechanism remains unclear, but
possibilities include ATP< ANG11 or a slow component of MR.

Autoregulation of blood flow describes the function of a vascular bed to maintain its perfusion
constant despite variations of the level of arterial pressure. This function is present in almost any
tissue but particularly pronounced in some organs such as the brain and the kidney.

Autoregulation of RBF is based on two mechanisms, the myogenic (MR) response and the
tubuloglomerular feedback (TGF).

MR is a function of smooth muscle to contract in response to external stretching force. In the

case of vascular smooth muscle, this causes vasoconstriction on a rise in arterial pressure thus
allowing for autoregulation.

Tubuloglomerular feedback mechanisim: Here the kidney changes its own blood flow in
response to changes in sodium concentration. The sodium chloride levels in the urinary filtrate
are sensed by the macula densa cells at the end of the ascending limb. When sodium levels are
moderately increased, the macula densa releases ATP and reduces prostaglandin E2 release to
the juxtaglomerular cells nearby. The juxtaglomerular cells in the afferent arteriole constrict, and

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juxtaglomerular cells in both the afferent and efferent arteriole decrease their renin secretion.
These actions function to lower GFR. Further increase in sodium concentration leads to the
release of nitric oxide, a vasodilating substance, to prevent excessive vasoconstriction. In the
opposite case, juxtaglomerular cells are stimulated to release more renin, which stimulates
the renin-angiotensin system, producing angiotensin I which is converted by Angio-Tensin
Converting Enzyme (ACE) to angiotensin II. Angiotensin II then causes preferential constriction
of the efferent arteriole of the glomerulus and increases the GFR.

Figure 3: MAJOR HORMONES THAT INFLUENCE GFR & RBF

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Figure4: AUTOREGULATION OF GFR AS MEAN ARTERIAL BLOOD PRESSURE
INCREASES

The overall speed of RBF autoregulation is crucial, because the kidney vasculature is
continuously challenged by fluctuations of pressure over a broad range of frequencies from cycle
length of seconds and minutes to hours and days. Since auto regulation determines the amount of
pressure fluctuations reaching the glomerulus, peritubular capillaries and medullary circulation
its function is potentially important for filtration, reabsorption, and pressure natriuresis and
hypertensive renal damage. Renal autoregulation minimizes the impact of changes in arterial
blood pressure on sodium excretion. Without renal autoregulation, increased in arterial blood
would lead to dramatic losses of sodium chloride and water from the ECF.

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