L GY

N A O
E OL
R SI
HY
P

Urine
formation
 Body fluid
compartments
In the average young adult
male, 18% of the body
weight is protein and
related substances, 7% is
mineral, and 15% is fat.
The remaining 60% is
water.
The volume of distribution is equal to the amount injected (minus any that has
been removed from the body by metabolism or excretion during the time
allowed for mixing) divided by the concentration of the substance in the sample.
Example: 150 mg of sucrose is injected into a 70 kg man. The plasma sucrose
level after mixing is 0.01 mg/mL, and 10 mg has been excreted or metabolized
during the mixing period. The volume of distribution of the sucrose is

Perhaps the most accurate measurement of ECF volume is that obtained by

using inulin, a polysaccharide. Mannitol and sucrose have also been used to
measure ECF volume.
Plasma volume has been measured by using dyes that become bound to plasma
protein—particularly Evans blue (T-1824). If one knows the plasma volume and
the hematocrit (ie, the percentage of the blood volume that is made up of cells),
the total blood volume can be calculated by multiplying the plasma volume by

The volume of the interstitial fluid can be calculated by subtracting the plasma
volume from the ECF volume. The ICF volume can be calculated by subtracting
the ECF volume from the TBW. TBW can be measured by the same dilution
principle using deuterium oxide (D2O, heavy water).
 Electrolytes and other charged compounds (eg,
proteins) are unevenly distributed in the body fluids
 Volume contraction (dehydration)
Isosmotic volume contraction Hyperosmotic volume
contraction
(hemorrhage)

Hyposmotic volume
contraction
 Volume expansion (Overhydration)
Isosmotic volume expansion Hyperosmotic
Volume expansion

Hyposmotic volume
expansion
(SIADH)
• A 67-year-old woman involved in a motor vehicle
accident lost 1 L of blood because of an open fracture of
her left femur. Paramedics were able to prevent further
bleeding. What changes to her intracellular fluid (ICF)
and extracellular fluid (ECF) volumes would be observed
15 minutes after this blood loss?
A. ECF volume smaller; ICF volume unchanged
B. ECF volume smaller; ICF volume smaller
C. ECF volume unchanged; ICF volume unchanged
D. ECF volume unchanged; ICF volume smaller
Defense of Tonicity
• The total body osmolality is directly proportional to the total body

sodium plus the total body potassium divided by the total body

water, so that changes in the osmolality of the body fluids occur

when a disproportion exists between the amount of these

electrolytes and the amount of water ingested or lost from the body.
Osmolality (mOsm/L) = 2[Na+] (mEq/L) + 0.055[Glucose] (mg/dL) +

0.36[BUN] (mg/dL)

• Plasma osmolality ranges from 280 to 295 mOsm/kg of H2O, with

vasopressin secretion maximally inhibited at 285 mOsm/kg and

stimulated at higher values.

Cortical &
Juxta-
medullary
nephron
Juxtaglomerular apparatus

• JG cells – secrete
renin
• Macula densa –
senses changes in
volume & ↓ in
NaCl conc.
• Mesangial cells
Renin-Angiotensin-Aldosterone pathway
 Urine
formation
• Filtration
• Reabsorption
• Secretion

Excretion = Filtration –
Reabsorption + Secretion
 Glomerular filtration

Glomerular membrane
• Fenestrated
endothelium of
capillary
• Basement membrane
• Podocytes (epithelial
cells)
 Effective
filtration
pressure

Net filtration Glomerular Bowman’s Glomerular

pressure = hydrostatic – capsule – oncotic
(10mmHg) pressure (PG) pressure (PB) pressure (πG)
(60 mmHg) (18mmHg) (32mmHg)
 Glomerular filtration rate (GFR)
GFR = Kf x Net filtration pressure (PG – PB – πG + πB)
• Amount of filtrate formed by both kidneys together in
unit time is called GFR. Normal value is 125ml/min. i.e.,
180 L/day.
• Factors regulating glomerular filtration
– Filtering membrane: its size, pores, charge
– Particle size, shape, electrostatic charge
– Filtering forces
– Amount of blood flow
– Autoregulation
– Mesangial cells
– Sympathetic nerves
 Renal blood flow
Combined blood flow through both kidneys in an
average adult is 1100ml/min.
(Renal artery pressure – Renal vein pressure)
Renal blood flow =
Total renal vascular resistance

Renal vascular resistance is mainly offered by interlobular

arteries, afferent arterioles & efferent arterioles.

Efferent arterioles offer the maximum resistance, because the size

of efferent arteriole is smaller in comparison to afferent
arteriole, and creates a higher pressure in glomerulus, which
enhances glomerular filtration.
 Regulation of Glomerular filtration &
Renal blood flow
• Autoregulation
• Sympathetic nervous system
– Sympathetic stimulation → constriction of renal
arterioles → ↓ RBF & GFR
• Hormonal control
– Norepinephrine, epinephrine & endothelin → ↓ GFR & RBF
– Nitric oxide, prostaglandins & bradykinin → ↑ GFR & RBF
– Angiotensin II → constricts efferent arteriole → ↑ GFR &
↓RBF, & also ↑ Na & water reabsorption due to efferent
arteriolar constriction causing reduced flow in peritubular
capillaries.
 Myogenic autoregulation
Autoregulation Tubuloglomerular feedback
Macula densa
feedback
mechanism for
autoregulation
of GFR during
decreased renal
arterial
pressure.
 Plasma clearance
• The plasma clearance (renal clearance) of a substance is
the volume of plasma that is cleared of the substance by
the kidneys in unit time.

Clearance = Urine conc. Of SubA X rate (volume) of urine formation

Plasma conc. of SubA
Plasma clearance of inulin or creatinine can be used for the
measurement of GFR, as these substances are completely filtered
and it is not reabsorbed nor secreted. So the plasma clearance is
equal to GFR.
Renal plasma flow & renal blood flow can be estimated by
measuring the plasma clearance of substances which are filtered &
secreted, but not reabsorbed. Example for such a substance is para
amino hippuric acid (PAH)
S, a substance; U, urine concentration; •V, urine flow rate; P, plasma concentration; PAH,
para-aminohippuric acid; PPAH, renal arterial PAH concentration; EPAH, PAH extraction ratio;
VPAH, renal venous PAH concentration.
 Example:
• Concentration of PAH in urine (U ): 14 mg/mL
PAH

• Urine flow (V˙): 0.9 mL/min

• Concentration of PAH in plasma (P ): 0.02 mg/mL
PAH

• ERPF = = 630mL/min

• ERPF can be converted to actual renal plasma flow (RPF):

• Average PAH extraction ratio: 0.9

From the renal plasma flow, the renal

blood flow can be calculated by dividing
by 1 minus the hematocrit:

Hematocrit (Hct): 45%

 Tubular Reabsorption
• Transcellular (transepithelial) absorption
• Paracellular absorption
 Sodium & chloride reabsorption
• Na is reabsorbed in PCT, thick segment & distal nephron.
Except in thin segment.
Mechanisms
In PCT : 65 – 70%
• Unidirectional Na transport: Movement of sodium against
concentration gradient. Glucose, aminoacids, phosphate etc. are co-
transported with it.
• Na+ – H+ exchange (antiport)
In thick ascending limb : 25%
• 1Na+ – 1K+ – 2Cl– symportor.
Distal nephron : 10%
• Unidirectional Na transport, but under the influence of
aldosterone.
 Glucose & amino acid reabsorption
• Reabsorbed in PCT – Na co-transport mechanism.
SGLT (Na dependent glucose trans-
porter) on the luminal (apical) mem-
brane & GLUT (glucose transporter)
on the basolateral membrane.
 Reabsorption of water
• Passive transport by osmosis (coupled to Na
reabsorption)
• Proximal tubule : 65 – 70%
• Solvent drag through paracellular route – water
takes Na, Cl, K, Ca, Mg etc along with it.
• Distal tubule & collecting duct : ADH control
Potassium reabsorption & secretion
• In PCT solvent drag through paracellular route
cause reabsorption. Minimal secretion of K +
occurs through the luminal membrane.
• In thick ascending limb 1Na+–1K+–2Cl– co-
transportation cause reabsorption
• In late distal tubule & collecting duct, principal
cells reabsorb Na & secrete K. And the
intercalated cells reabsorb K & HCO 3– and
secrete H+ ions.
 Hydrogen ion secretion
PCT
• Na+ – H+ counter
transport
Distal tubule &
collecting tubule
• Intercalated cells
• H+ ATPase (primary
active transport)
 Ammonium ion secretion

Glutamine is
metabolized in
PCT cells
yielding NH4+ and
bicarbonate. The
NH4+ is actively
secreted by Na –
NH4+ pump and
bicarbonate is
returned to blood.
Tubular
Reabsorption
& Secretion
 Urine Concentration & Dilution
• Formation of dilute or concentrated urine
depends on
• Hormones (ADH, aldosterone)
• Medullary concentration gradient
– Counter current Mechanism
• Counter current multiplier
• Counter current exchanger
 Medullary concentration gradient
• Active transport of Na, K, Cl etc out of
ascending limb (especially thick limb) of loop of
Henle to the medullary interstitium.
• Active transport of ions from collecting duct to
medullary interstitium.
• Passive diffusion of urea from medullary
collecting ducts into the medullary interstitium.
• Diffusion of less amounts of water from
medullary tubules into medullary interstitium
Counter current mechanism
 Urea recycling
Thick ascending
limb, DCT &
cortical collecting
duct is impermeable
to urea.
Urea is permeable
through medullary
collecting duct
(permeability is
enhanced by ADH).
Urea move out from
medullary CT, and
enters into thin limbs of
loop of Henle
 Free-Water Clearance
• Free-water clearance is calculated as the difference
between water excretion (urine flow rate) and osmolar
clearance:

• When the kidneys are forming a dilute urine (i.e., urine

osmolarity is less than plasma osmolarity), free-water
clearance will be a positive value, denoting that water is
being removed from the plasma by the kidneys in excess
of solutes.
• Whenever urine osmolarity is greater than plasma
osmolarity, free-water clearance is negative, indicating
water conservation.
 Control of urine formation
• Nervous regulation – Sympathetic nerve (+) – overall effect is to ↑
reabsorption & ↓ excretion of sodium
• Constriction of renal arterioles – GFR ↓
• ↑ Tubular reabsorption of Na & water
• Activation of Renin – AgII – Aldosterone system
• Hormonal regulation
 ADH – Distal nephron – ↑H2O reabsorption
 Aldosterone – Collecting tubule – ↑NaCl, ↑H2O reabsorption & ↑K secretion
 Angiotensin II – PCT, thick ascending limb, DCT – ↑NaCl, ↑H 2O
reabsorption & ↑H secretion
 Atrial natriuretic peptide – Distal nephron – ↓NaCl reabsorption
 Parathyroid hormone – PCT, thick ascending limb, DCT – ↓phosphate &
↑Ca reabsorption
• Glomerulotubular balance – The ability of the tubules to increase
reabsorption rate in response to increased tubular load (glomerular filtration)
Mechanism of
ADH action on
Distal nephron
 Mechanism of Angiotensin II
Mechanism of Aldosterone
action on proximal nephron
action on Distal nephron
 Mechanism of action of various diuretics
Agent
Water
Ethanol
Antagonists of V2 vasopressin
receptors such as tolvaptan
Large quantities of osmotically
active substances such as
mannitol and glucose
Xanthines such as caffeine and
theophylline
Acidifying salts such as CaCl2
and NH4Cl
Mechanism of Action
Inhibits vasopressin secretion
Inhibits vasopressin secretion
Inhibit action of vasopressin on
collecting duct
Produce osmotic diuresis
Decrease tubular reabsorption
of Na+ and increase GFR
Supply acid load; H+ is buff
ered, but an anion is excreted
with Na+ when the ability of the
kidneys to replace Na+ with H+
is exceeded
 Mechanism of action of various diuretics
Agent Mechanism of Action
Carbonic anhydrase inhibitors Decrease H + secretion, with
such as acetazolamide (Diamox) resultant increase in Na+ and K+
excretion
Loop diuretics such as Inhibit the Na–K–2Cl
furosemide (Lasix), ethacrynic cotransporter in the medullary
acid (Edecrin), and bumetanide thick ascending limb of the loop
of Henle
Metolazone (Zaroxolyn), Inhibit the Na–Cl cotransporter
thiazides such as chlorothiazide in the early portion of the distal
(Diuril) tubule
K + -retaining natriuretics such Inhibit Na+ –K+ “exchange” in
as spironolactone (Aldactone), the collecting ducts by inhibiting
triamterene (Dyrenium), and the action of aldosterone
amiloride (Midamor) (spironolactone) or by inhibiting
the ENaCs (amiloride)
Micturition

(Sympathetic)

(Parasympathetic)

(Somatic)
Normal cystometrogram
 Micturition reflex
Filling of urinary bladder → stretch receptors → sensory
impulse via pelvic nerve to S2 – S4 → Parasympathetic impulse
via pelvic nerve → Contraction of detrusor muscle & relaxation
of internal sphincter → urine in urethra stimulates stretch
receptors → sensory impulse via pelvic nerve to S2 – S4 →
inhibition of somatic fibers in pudendal nerve → relaxation of
external sphincter → results in urination

Sympathetic (through hypogastric nerve) stimulation of beta receptors

on detrusor muscle causes relaxation & of alpha receptors on internal
sphincter causes constriction of sphincter, hence sympathetic
stimulation causes filling & referred to as nerve of filling.
Higher brain centers of Micturition
• Facilitatory & inhibitory centers in brain stem
especially pons
• Centers located in cerebral cortex is normally
inhibitory but can become excitatory
• For voluntary urination, cortical centers can
facilitate the sacral micturition centers to help
initiate a micturition reflex & at the same time
inhibit the external urinary sphincter.