Urine Formation: Tubular

Processing of the Glomerular

Filtrate
Jethro Macallan, MD
Flow of urine pix
 Urinary Excretion =
Glomerular Filtration – Tubular
Reabsorption + Tubular
secretion
Filtration = Glomerular
filtration rate x Plasma
concentration
 Tubular Reabsorption
 Very large compared to urinary excretion
 Highly selective
 Completely reabsorbed: glucose and
amino acids
 Variable reabsorption: Na, Cl, HCO3
 Poorly reabsorbed: urea and creatinine
Filtration, Reabsorption, and Excretion Rates of Different Substances by
the Kidneys
Amount Amount Amount % of Filtered
Filtered Reabsorbed excreted Load
Reabsorbed
Glucose 180 180 0 100
(g/day)
Bicarbonate 4,320 4,318 2 >99.9
(mEq/day)
Sodium 25,560 25,410 150 99.4
(mEq/day)

Chloride 19,440 19,260 180 99.1

(mEq/day)

Potassium 756 664 92 87.8

(mEq/day)
Urea (g/day) 46.8 23.4 23.4 50
Creatinine 1.8 0 1.8 0
(g/day)
Table 41-2 Composition of urine

Substance Concentration

Na+ 50-130 mEq/L

K+ 20-70 mEq/L

NH4+ 30-50 mEq/L

Ca++ 5-12 mEq/L

Mg++ 2-18 mEq/L

Cl- 50-130 mEq/L

Pi 20-40 mEq/L

Urea 200-400 mM
Creatinine 6-20 mM
pH 5.0-7.0
Osmolality 500-800 mOsm/kg H2O

Glucose 0

Amino acids 0

Protein 0

Blood 0

Ketones 0

Leukocytes 0

Bilirubin 0
 Tubular Reabsorption
 Involves both active and passive
mechanisms
 Transcellular route
 Paracellular route
 Ultrafiltration (bulk flow)
 Tubular Reabsorption
 Active Transport
 Against an electrochemical gradient
 Requires ATP
 2 types:
1. Primary
2. Secondary
 Tubular Reabsorption
 Osmosis
 Water diffusion from a region of low solute
concentration to a region of high solute
concentration
 Primary Active Transport
 Can move solutes against an
electrochemical gradient
 Energy comes from the hydrolysis of ATP
 Includes the following:
1. Na-K ATPase
2. Hydrogen ATPase
3. H-K ATPase
4. Ca ATPase
 Primary Active Transport
 Na-K ATPase
 Transports Na ions into the interstitium
 Maintains: 1) low intracellular Na and 2)
high intracellular K
 End result: -70mV inside the cell
 Primary Active Transport
 Na- K ATPase
 Involves 3 steps:
1. Na diffuses across the apical membrane
into the cell membrane
2. Na is transported by the Na-K ATPase
pump
3. Na, water and other substances are
reabsorbed to the peritubular capillaries
by ultrafiltration
Na- K pump pix
 Secondary Active Transport
 2 or more substances interact with a
carrier molecule and are transported
together across the membrane
 Does not require energy directly from ATP
and from high energy phosphate sources
 Can either be co-transport and counter-
transport
Glucose and amino acid co-
transport
Na-H countertransport
 Secondary Active Transport
 Pinocytosis
 Reabsorbs large molecules eg. Proteins
 Requires energy
 Secondary Active Transport
 Transport maximum
 Limit to transport of solute (reabsorption
and/or secretion)
 Saturation of specific transport systems
 Tubular load exceeds the capacity of the
carrier proteins
 Can be increased by hormones, eg.
aldosterone
 Secondary Active Transport
 Glucose Transport System
 Found in the proximal tubule
 All filtered glucose is reabsorbed
 Transport maximum: 375mg/min – all
nephrons have reached their maximal
capacity to reabsorb glucose
 Filtered load of glucose: 125mg/min
 Secondary Active Transport
 Threshold for glucose
 Appearance of glucose in the urine
 Occurs before the transport maximum is
reached
 Reason: not all nephrons have the same
transport maximum for glucose
Transport Maximum of Substances
Actively Reabsorbed
Substance Transport Maximum

Glucose 375mg/min
Phosphate 0.10 mM/min
Sulfate 0.06 mM/min
Amino acids 1.50 mM/min
Urate 15 mg/min
Lactate 75 mg/min
Plasma protein 30 mg/min
Transport Maximum of Substances
Actively Secreted

Substance Transport Maximum

Creatinine 16 mg/min
PAH 80mg/min
 Actively Transported but No
Transport Maximums
 Substances that are passively
reabsorbed do NOT demonstrate a
transport maximum
 Gradient-Time Transport
 Also seen in some actively transported
substances, eg. Na reabsorption
 Determined by:
1. Electrochemical gradient for diffusion
2. Permeability of the membrane for the
substance
 Water Reabsorption
 Occurs through osmosis
 Osmotic flow of water occurs through the
tight junctions
 Seen in the proximal tubule – high
permeability for water and most ions
 Water Reabsorption
 Solvent Drag
 Solutes carried when water moves across
the tight junctions by osmosis
 Changes in Na reabsorption influence
reabsorption of water and solutes
 Water Reabsorption
 Proximal Tubule – high
 Loop of Henle – low
 Last part of the tubules – high or low
 Passive Diffusion of Cl, urea and
other solutes
 Cl ion diffusion
 Caused by electric potentials brought
about by Na
 Na goes out leaving the inside negatively
charged compared to the interstitial fluid
 Diffuses through the paracellular pathway
 Can be reabsorbed by secondary active
transport, eg. Na-Cl co-transport
 Na+ reabsorption

H2O reabsorption

Lumen
Luminal Cl- Luminal urea
negative
concentration concentration
potential

Passive Cl- Passive urea

reabsorption reabsorption
 Passive Diffusion of Cl, urea and
other solutes
 Urea
 Passively reabsorbed from the tubule
 Increases as water is reabsorbed from the
tubules
 Urea transporters
In the inner medullary collecting duct
½ that is filtered is reabsorbed
 Passive Diffusion of Cl, urea and
other solutes
 Creatinine
 Larger than urea
 All that is filtered is excreted in the urine
10 minute break
Reabsorption and Secretion
Along the Different Parts of
the Nephron
 Proximal Tubule
 Reabsorbs about 65% of the filtered load
of Na and water
 Highly metabolic and have large numbers
of mitochondria
 Extensive brush border on the luminal side
 Rapid Na reabsorption
 Loaded with protein carrier molecules
Co-transport: glucose and amino acids
Counter-transport: hydrogen ions
 Proximal Tubule
 Na-K ATPase pump
 Major force for the reabsorption of NaCl
and water
 1st half of the tubule: co-transport with aa,
glucose
 2nd half of the tubule: co-transport with Cl
 Proximal Tubule
 Solute concentration along the Proximal
tubule
 [Na] remains constant
 Glucose, amino acids and HCO3 are
avidly reabsorbed
 [creatinine] increases
 Proximal Tubule
 Secretion of Organic acids and bases
 eg. Bile salts, oxalate, urate,
cathecholamines
 Secretion + filtration + no reabsorption =
rapid excretion
 Penicillin and salicylates: rapidly excreted
by the kidneys
 PAH: rapidly excreted

- Used to estimate renal plasma flow

 Loop of Henle
 Divided into 3 segments:
1. Thin descending segment
2. Thin ascending segment
 No brush borders
 Few mitochondria
 Minimal levels of metabolic activity

3. Thick ascending segment

 Loop of Henle
 Descending Segment
 Highly permeable to water
 Moderately permeable to most solutes~Na
and urea
 Function: simple diffusion through its walls
 Reabsorbs almost 20% of the filtered
water
 Does not reabsorb Ca, Mg, HCO3
 Loop of Henle
 Ascending Limb
 Both thin and thick
 Impermeable to water – important in
concentrating the urine
 Na-K 2Cl co-transport
Mediates movement of Na across the
luminal membrane
 Loop of Henle
 Thick Ascending Limb
 High metabolic activity
 Active reabsorption of Na, Cl and K ~25%
 Also reabsorbs Ca, Mg and HCO3
 Na-K ATPase pump
Low intracellular [Na]
 Site of action of loop diuretics (furosemide,
ethacrynic acid, bumetanide)
 Loop of Henle
 Thick Ascending Limb
 Na-H counter-transport
Mediates Na reabsorption
Secretes hydrogen ions
 Impermeable to water
 Early Distal Tubule
 Forms part of the juxtaglomerular complex –
provides feedback control of GFR and blood flow
 Reabsorbs Na (5%), K and Cl
 Impermeable to water and urea
 Na-Cl co-transport
 Moves Na and Cl from the lumen into the cell
 Na-K ATPase
 Pumps Na out of the cell across the basolateral
membrane
 Site of action of thiazide diuretics
 Late Distal Tubule and Cortical
Collecting tubule
 Composed of 2 distinct cell types:
1. Principal Cells
 Reabsorb Na and water from the lumen
 Secrete K ions to the lumen

2. Intercalated Cells
 Reabsorb K ions
 Secrete hydrogen ions into the lumen
 Late Distal Tubule and Cortical
Collecting tubule
 Principal Cells
 Depends on the activity of the Na-K
ATPase pump
 Na reabsorption and K secretion
 Primary sites of K sparing diuretics
1. Aldosterone antagonists: spironolactone,
eplerenone
2. Na channel blockers: amiloride,
triamterene
 Late Distal Tubule and Cortical
Collecting tubule
 Intercalated Cells
 Mediated by a hydrogen ATPase
mechanism
 Secrete hydrogen ions and reabsorbs K
 Plays a key role in acid base regulation of
body fluids
 Late Distal Tubule and Cortical
Collecting tubule
 Functional characteristics:
1. Completely impermeable to urea
2. Reabsorb Na ions – controlled by
aldosterone
3. Intercalated cells – acid-base regulation
4. ADH/ vasopressin – controls permeability
to water
 Medullary Collecting Duct
 Absorbs <10% of filtered Na and water
 Final site of processing of urine
 Important role in final urine output of water
and solutes
 Epithelial cells are cuboidal in shape
 Relatively few mitochondria
 Medullary Collecting Duct
 Special characteristics:
1. Permeability is controlled by ADH
2. Permeable to urea
3. Secretes hydrogen ions – role in acid-
base balance
 Medullary Collecting Duct
 > 1.0 : more water is reabsorbed than
solute; net secretion of the solute into the
tubular fluid
 < 1.0 : more solute has been reabsorbed
than water
 1.0 : concentration of the substance in the
tubular fluid is the same as the
concentration in plasma
 Measurement of Water
Reabsorption
 Inulin
 Used to measure GFR
 Not secreted or reaborbed
 Changes in inulin reflect changes in the
amount of water in the tubular fluid
10 minute break
Regulation of Tubular
Reabsorption
 Glomerulotubular Balance
 Most basic mechanism for controlling
tubular reabsorption
 Intrinsic ability of the tubules to increase
their rate of reabsorption in response
increased tubular load
 Occurs independent of hormones
 Glomerulotubular Balance
 Total rate of reabsorption increases as the
filtered load increases
 Helps prevent the overloading of the distal
tubular segments when GFR increases
 Second line of defense: buffers
spontaneous changes in GFR on urine
output (first line: autoregulatory
mechanisms~ tubuloglomerular feedback)
review autoregulation
 Peritubular Capillary and Renal
Interstitial Fluid Physical Forces

 Normal rate of peritubular capillary

reabsorption: 124 ml/min
 Reabsorption = Kf x Net reabsorptive
forces
 Peritubular Capillary and Renal
Interstitial Fluid Physical Forces
 Starling Hypothesis
 Q = k[ (P + π ) – (P + π )]
f c i i p
where:
Q : fluid movement
f
k: filtration constant
P : capillary hydrostatic pressure
c
P : interstitial fluid hydrostatic pressure
i
π : plasma oncotic pressure
p
π : interstitial fluid oncotic pressure
i
 Peritubular Capillary and Renal
Interstitial Fluid Physical Forces
 Net reabsorptive forces
 Peritubular hydrostatic pressure (Pc):
opposes reabsorption ~ 13mmHg
 Interstitial fluid hydrostatic pressure (Pif):
favors reabsorption ~ 6mmHg
 Peritubular Capillary and Renal
Interstitial Fluid Physical Forces
 Net reabsorptive forces
 Peritubular colloid oncotic pressure (πc):
favors reabsorption ~ 32mmHg
 Interstitial fluid colloid oncotic pressure
(πif): opposes reabsorption ~ 15mmHg
 Peritubular Capillary and Renal
Interstitial Fluid Physical Forces
 Hydrostatic pressure:
 Pc - Pif
 13mmHg – 6 mmHg = 7mmHg: opposes
reabsorption
 Oncotic pressure:
 πc - πif
 32mmHg – 15 mmHg = 17mmHg: favors
reabsorption
 Peritubular Capillary and Renal
Interstitial Fluid Physical Forces
 Net reabsorptive forces
 Net hydrostatic forces - Net oncotic forces
 7mmHg – 17 mmHg = 10mmHg
 Favors net reabsorption
 Peritubular Capillary and Renal
Interstitial Fluid Physical Forces
 Filtration Coefficient (Kf)
 Contributes to the high rate of fluid
reabsorption
 Review:

Reabsorption = Kf x Net reabsorptive forces

 Normal Kf = 12.4 ml/min/mmHg

 Peritubular Capillary and Renal
Interstitial Fluid Physical Forces
 Regulation of Peritubular Capillary Physical
Forces
 determined by Pc and πc
 Pc - influenced by:
1. Arterial pressure
 Increases cause an increase in Pc and a
decrease in reabsorption
2. Resistances of the afferent and efferent
arterioles
 Increase in resistance causes an decrease in
 Peritubular Capillary and Renal
Interstitial Fluid Physical Forces
 Regulation of Peritubular Capillary
Physical Forces
 π - is determined by:
c
1. Systemic plasma colloid oncotic pressure
 Directly correlated to an increase in
[plasma protein] : reabsorption
2. Filtration Fraction (GFR/ renal plasma
flow)
- Directly correlated to reabsorption rate
 K is directly correlated to peritubular
f
Factors That Can Influence
Peritubular Capillary Reabsorption
↑PC →↓Reabsorption
 ↓RA →↑PC
 ↓RE →↑Ra
 ↑Arterial Pressure→↑PC
↑πC →↑Reabsorption
 ↑πA →↑πC
 ↑FF →↑πC
↑Kf →↑Reabsorption
 Peritubular Capillary and Renal
Interstitial Fluid Physical Forces
 Renal Interstitial and Colloid Oncotic
Pressures
 Peritubular capillary reabsorption is
directly correlated with tubular
reabsorption of water and solutes
 Effect of Arterial Pressure
 Increased arterial pressure causes:
 Much larger increases in GFR
 A decrease in the filtered load of Na and
water that is reabsorbed in the tubules
 Hormonal Control
 Aldosterone
 Angiotensin II
 ADH
 ANP
 Parathyroid Hormone
 Hormonal Control
 Aldosterone
 Secreted by the zona glomerulosa of the
adrenal cortex
 Acts on the principal cells of the cortical
collecting tubule
 Stimulates Na reabsorption and K
secretion
 More important regulator of K than Na
 Addison’s disease – decreased
aldosterone
 Hormonal Control
 Angiotensin II
 Most powerful Na retaining hormone
 Increases during times of: low BP,
hemorrhage and loss of water and Na
 Effects:
1. Stimulates aldosterone secretion
2. Constricts afferent arterioles
3. Directly stimulates Na reabsorption
 Hormonal Control
 ADH
 Key role in the degree of
dilution/concentration of the urine
 Increases water permeability of the distal
tubule, collecting tubule and collecting
duct
 Binds to V2 receptors
 Stimulates AQP-2: form water channels
and permit rapid diffusion of water
 Hormonal Control
 ANP
 Secreted by cells of the cardiac atria
 Responds to plasma volume expansion
 Acts on the collecting duct
 Inhibits reabsorption of Na and water
 Increases urine excretion
 Hormonal Control
 Parathyroid Hormone
 Important in Ca regulation
 Increases tubular reabsorption of Ca
 Inhibits phosphate reabsorption
 Stimulates Mg reabsorption
Hormones That Regulate Tubular Reabsorption
Hormone Site of Action Effects
Aldosterone Collecting tubule and ↑ NaCl, H2O
duct reabsorption, ↑K+
secretion
Angiotensin II Proximal tubule, thick ↑ NaCl, H2O
ascending loop of reabsorption, ↑H+
Henle/distal tubule, secretion
collecting tubule

Antidiuretic Distal tubule/ collecting ↑ H2O reabsorption

hormone tubule and duct
Atrial natriuretic Distal tubule/ collecting ↓ NaCl reabsorption
peptide tubule and duct
Parathyroid Proximal tubule, thick ↓ PO4--- reabsorption,
hormone ascending loop of ↑ Ca- reabsorption
Hental/distal tubule
 Sympathetic Nervous System
 Constricts the renal arterioles
 Decreases Na and water excretion
 Reduces GFR
 Increases Na reabsorption
 Increases renin release and Angiotensin II
formation
10 minute break
 Clearance Methods to
Quantify Renal Function
 Inulin
 Polyssacharide molecule with MW = 5200
 Not produced in the body
 Requires IV infusion
 Freely filtered
 Not reabsorbed or secreted
 Used to determine GFR ~ radioactive
iothalamate and creatinine
 Inulin
 Generalizations:
1. Filtered and not reabsorbed or secreted
– clearance rate of a substance equals
that of inulin
2. Reabsorbed - clearance rate of a
substance is less than that of inulin
3. Secreted - clearance rate of a substance
is greater than that of inulin
 Creatinine
 By-product of muscle metabolism
 Cleared almost entirely by glomerular
filtration
 Ca also be used to assess GFR
 Errors:
 A small amount is secreted by the tubules:
excreted creatinine exceeds amount
filtered
 Error in measurin plasma creatinine:
overestimate of plasma cratinine
 Creatinine
 Changes in GFR = [plasma creatinine]:
inversely proportional to GFR
 Creatinine excretion rate equals its
production
 Excretion = GFR x Pcreatinine
Table 40-1 Major hormones that influence GFR and RBF
Stimulus Effect on GFR Effect on RBF
Vasoconstrictors
Sympathetic ↓ ECV ↓ ↓
nerves
Angiotensin II ↓ ECV, renin ↓ ↓

Endothelin Shear stress, angiotensin ↓ ↓

II, bradykinin, epinephrine
Vasodilators
Prostaglandins ↓ ECV, shear stress, NC ↑
(PGI2, PGE2) angiotensin II

Nitric oxide Shear stress, ↑ ↑

acetylcholine, histamine,
bradykinin, adenosine
triphosphate
Bradykinin Prostaglandin, ↓ ↑ ↑
angiotensin converting
enzyme
 Renal Plasma Flow
 Clearance rate of a substance that is
completely cleared of plasma
 No known substance that is completely
cleared by kidneys
 Para-aminohippuric acid
 90% cleared from the plasma ~ extraction
ratio of PAH
 Filtration Fraction
 = GFR/ RPF
 = inulin clearance/ PAH clearance
 = 125/ 650
 = 0.19
Use of Clearance to Quantify Kidney Function

Term Equation Units

Clearance rate (Cs) ml/min

Glomerular filtration rate

(GFR)  

Clearance ratio None

Effective renal plasma flow ml/min

(ERPF)
Renal plasma flow ml/min
(RPF)

Renal blood flow (RBF) ml/min

Excretion rate Excretion rate = Us x V mg/min,

mmol/min, or
mEq/min

Reabsorption rate Reabsorption rate = Filtered load – Excretion mg/min,

rate mmol/min, or
= (GFR x Ps) – (Us x mEq/min
V)

Secretion rate Secretion rate = Excretion rate – Filtered load mg/min,

mmol/min, or
mEq/min
Substance Clearance rate
(ml/min)
Glucose 0
Sodium 0.9
Chloride 1.3
Potassium 12.0
Phosphate 25.0
Inulin 125.0
Creatinine 140.0
Summary
Table 41-3 NaCl transport along the nephron
Segment Percentage filtered Mechanism of Na+ Major regulatory
reabsorbed entry across the hormones
apical membrane
Proximal tubule 67% Na+-H+exchange, Angiotensin II
Na+-cotransport with
amino acids and Norepinephrine
organic solutes,
Na+/H+-Cl-/anion
Epinephrine
exchange

Dopamine
Paracellular
Loop of Henle 25% 1 Na+-1K+-2Cl- Aldosterone
symport
Distal tubule ~4% NaCl symport Aldosterone

Late distal tubule ~3% Na+ channels Aldosterone

and collecting duct
Atrial natriuretic
peptide
Urodilatin
Table 41-4 Water transport along the nephron

Segment Percentage of Mechanism of Hormones

filtered load water that regulate
reabsorbed reabsorption water
Proximal tubule 67% Passive permeability
None

Loop of Henle 15% DTL only; None

passive

Distal tubule 0% No water None

reabsorption

Late distal ~8%-17% Passive ADH, ANP

tubule and
collecting duct
Hormones That Regulate Tubular Reabsorption
Hormone Site of Action Effects
Aldosterone Collecting tubule and ↑ NaCl, H2O
duct reabsorption, ↑K+
secretion
Angiotensin II Proximal tubule, thick ↑ NaCl, H2O
ascending loop of reabsorption, ↑H+
Henle/distal tubule, secretion
collecting tubule

Antidiuretic Distal tubule/ collecting ↑ H2O reabsorption

hormone tubule and duct
Atrial natriuretic Distal tubule/ collecting ↓ NaCl reabsorption
peptide tubule and duct
Parathyroid Proximal tubule, thick ↓ PO4--- reabsorption,
hormone ascending loop of ↑ Ca- reabsorption
Hental/distal tubule
Thank You!!!