Kidney International, VOL II (l977)p.
1-8
Site of action of diuretic drugs
Diuretic drugs continue to attract the interest of
renal physiologists not only for their intrinsic tubular
effects but equally importantly for the insight that
such studies provide into normal and abnormal
mechanisms of renal function. Much new informa-
tion has accumulated in recent years from experi-
ments at a single nephron level particularly as a result
of work on the isolated kidney tubule initiated by
Burg and his collaborators [1, 2]. This makes it ap-
propriate at the present time to review current knowl-
edge about the site of action of commonly used diu-
retics with particular attention to the results of
micropuncture studies. We plan to consider the avail-
able evidence in each segment of the nephron for the
following groups of drugs: the potent loop diuret-
ics—furosemide, ethacrynic acid and mercurials; the
benzothiadiazides, or simply the thiazide group of
diuretics; the carbonic anhydrase inhibitors; and the
potassium—sparing diuretics.
Before considering the specific action of diuretic
drugs on the transport of water and electrolytes in the
renal tubule, brief attention should be given to their
effects on glomerular filtration since such effects may
influence to a major extent the magnitude of the
diuresis. The use of all diuretic drugs is often asso-
ciated with a decrease in filtration rate for reasons
that are not entirely clear. An important factor ap-
pears to relate to secondary changes in extracellular
fluid (ECF) volume. Burke, Robinson, and Clapp [3]
have shown that the decrease in glomerular filtration
rate (GFR) that occurs following an administra-
tion of furosemide can be prevented if the diu-
retic—induced volume losses are adequately replaced.
The same laboratory [4], however, has found that
another potent loop diuretic, ethacrynic acid, still
occasionally causes a fall in GFR despite concurrent
replacement of fluid losses. In view of the action of
these drugs on peripheral venous compliance and
venous return [5—7], which appears to be independ-
ent of their renal effects, it is not surprising that
changes in renal hemodynamics and filtration rate
may occur despite prevention of ECF volume deple-
tion, mediated perhaps through subtle changes in
Received for publication April 22, 1976:
and in revised form August 27, 1976.
© 1977, by the International Society of Nephrology.
I
EDITORIAL REVIEW
cardiac output. It is likely that the mechanism
whereby ECF volume losses lead to decreases in
GFR is related to a reduction in glomerular capillary
plasma flow [8], although there have been no direct
studies to establish this point. Other diuretics, such as
thiazides, mercurials, and carbonic anhydrase inhib-
itors, invariably cause a decrease in GFR whether
diuretic losses are replaced or not, clearly indicating
other mechanisms rather than changes in ECF vol-
ume in the control of filtration rate. Recent evidence
presented by Wright and Schnermann [9, 10] sup-
ports the notion that these effects may in part be
mediated by an intrarenal feedback mechanism
which couples distal salt delivery to filtration rate in
individual nephrons.
Proximal convoluted tubule. The various hemody-
namic and possibly intrarenal effects of diuretics have
made detection of primary transport effects within
the proximal convoluted tubule very difficult to es-
tablish with certainty. The only drugs at the present
time for which the evidence strongly supports a major
inhibitory action on proximal salt and water reab-
sorption are the carbonic anhydrase inhibitors and
the thiazide diuretics. The carbonic anhydrase inhib-
itor acetazolamide has been extensively studied using
a variety of techniques. Virtually all groups using this
drug have demonstrated inhibitory effects within the
proximal tubule. The magnitude alone of the urinary
bicarbonate losses that follow acetazolamide admin-
istration attests to a reduction in proximal bicarbo-
nate reabsorption and this has been subsequently
confirmed in free—flow micropuncture studies. The
aspect of much more recent interest relates to the
effects of carbonic anhydrase inhibition on sodium
and chloride reabsorption and whether or how such
effects can be attributed to the reduction of sodium
and bicarbonate reabsorption.
Free—flow micropuncture studies have repeatedly
shown that following carbonic anhydrase inhibition
there is a rise in tubular fluid to plasma (TF/P)
bicarbonate ratios [11—17]. This has also been re-
flected by a corresponding fall in TF/P chloride ra-
tios towards unity [14, 17—19]. Whereas earlier work
employing the quinhydrone electrode has reported
TF/P bicarbonate values in excess of unity after
acetazolamide administration, TF/P chloride values
do not fall below one, suggesting that the calculated
2 Seely and Dirks
bicarbonate results using this electrode were spur-
iously high. The reduction in bicarbonate reabsorp-
tion after acetazolamide administration has been at-
tributed to a reduction in active hydrogen ion
secretion across the luminal cell membrane, which is
in line with current concepts of bicarbonate reabsorp-
tion [20]. Malnic et al [21]'have studied the effects of
acetazolamide on the rate of intratubular acid-
ification of split—drops of known buffer composition.
Their results suggest that acetazolamide inhibits the
active step of hydrogen ion secretion as well as reduc-
ing passive permeability of the epithelium to bicarbo-
nate.
Several free—flow studies have demonstrated that in
addition to the effects on bicarbonate transport the
fractional reabsorption of sodium, chloride and
water was also reduced after carbonic anhydrase
inhibition [17, 22, 23]. Kunau [17] has reported
that another potent carbonic anhydrase inhibitor,
benzolamide, significantly reduced proximal frac-
tional reabsorption of chloride by 29%, sodium by
34%, and bicarbonate by 55%. Earlier reported stud-
ies, in which volume losses were not replaced, had
given equivocal results [14, 24, 25]. Several groups
have also shown a reduction in volume reabsorption
measured by the split oil droplet technique [26, 27].
Grantham [28] has reported a reduction in absorp-
tion from both convoluted and straight portions of
the proximal tubule using a modified in vitro tech-
nique to study the isolated rabbit tubule. The studies
of Radtke et al [26], which have shown a pro-
longation of the split—droplet half—time in the ab-
sence of bicarbonate using the organic buffer glyco-
diazine, were interpreted to mean that acetazolamide
may also inhibit a noncarbonic anhydrase mediated
hydrogen ion secretory transport system.
The mechanism whereby sodium and chloride
transport is inhibited secondary to the inhibition of
bicarbonate reabsorption is still unsettled at the pres-
ent time. Chloride transport appears to be passively
driven down a favourable electrochemical gradient
created by the preferential reabsorption of sodium
bicarbonate. The rise in luminal chloride concentra-
tion generates a small diffusion potential, lumen posi-
tive in the later portions of the proximal convoluted
tubule [18, 29, 30]. It is possible that this could also
facilitate the passive reabsorption of sodium in this
segment in view of the high permeability to sodium
and low electrical resistance of this portion of the
nephron [31—33]. Interference with preferential bi-
carbonate reabsorption by acetazolamide, which has
been shown to result in lower IF/P chloride ratios in
the late proximal tubule, leads therefore to a smaller
positive potential [18, 29, 34] and thus might account
for the inhibition of sodium and chloride reabsorp-
tion that occurs. This scheme, though attractive,
lacks firm experimental support. Furthermore, direct
testing of this hypothesis in the in vitro perfused
rabbit proximal tubule failed to show any consistent
relationship between fluid absorption and the trans-
epithelial potential difference [35]. An alternative hy-
pothesis recently proposed by Frömter [36] and by
Schafer, Patlak, and Andreoli [37] appears more
likely. This attributes the coupling of solute and wa-
ter transport to the fact that the transported bicarbo-
nate species has a higher reflection coefficient than
chloride. The positive potential difference is a con-
sequence of the transepithelial chloride gradient un-
der in vivo conditions, but is not of itself a driving
force for solute reabsorption.
Certain ones of the thiazide diuretics which have
been studied by micropuncture exhibit many of the
same effects as acetazolamide on the proximal tubule,
although their net effects on the whole kidney show
some important differences, The early micropuncture
study of Dirks, Cirksena, and Berliner [24] failed to
show inhibition of fractional reabsorption in the
proximal tubule after hydrochlorothiazide adminis-
tration, probably as a result of a failure to prevent
diuretic—induced ECF volume losses and consequent
large falls in GFR. A subsequent study from the same
laboratory [38] has shown a small depression in prox-
imal fractional reabsorption (10 to 15%) after chloro-
thiazide administration in the dog under both hydro-
penic and mild saline—loaded conditions. When
volume losses were replaced, Fernandez and Puschett
[39] have also shown that both chlorothiazide and a
related drug, metolazone, inhibit fractional sodium
and water reabsorption in the proximal tubule of
hydropenic parathyroidectomized dogs, provided
that the GFR did not drop by more than 26%. Sev-
eral groups have shown that chlorothiazide leads to a
depression of split—drop reabsorption [27, 28, 40]. In
recent studies of Kunau, Weller, and Webb [41], frac-
tional chloride reabsorption was reduced by chloro-
thiazide to the same extent as by the carbonic anhy-
drase inhibitor benzolamide. End proximal TF/P
chloride values were similarly reduced by both drugs.
These similarities suggest that the proximal effect of
chlorothiazide may be attributable to inhibition of
carbonic anhydrase. However, metolazone, which is
not a carbonic anhydrase inhibitor, resulted in a sim-
ilar depression of proximal fractional reabsorption.
Unfortunately, no direct studies of bicarbonate trans-
port in the proximal tubule are yet available with
either drug. Nevertheless, it is clear that the major
differences in the whole kidney effects of thiazides
and acetazolamide must be due to their action be-
yond the proximal tubule.
The evidence for a proximal tubular effect of drugs
 Diuretic site of action
known to exert major inhibitory effects on the loop of
Henle, i.e. ethacrynic acid, furosemide and the mer-
curials, is much more conflicting. In part, the reason
for this appears to be related to their hemodynamic
effects. Dirks, Cirksena and Berliner [24] have shown
that the use of all three drugs led to large decreases in
GFR and increases in proximal fractional reabsorp-
tion. This was attributed to the volume depletion that
ensued, since diuretic losses were not replaced. More-
over, this seemed likely in view of their previous
demonstration that acute volume expansion led to a
reduction in proximal fractional reabsorption [42].
Furthermore, when losses were replaced during etha-
crynic acid administration, fractional reabsorption
was then found to be unchanged. Several studies have
subsequently confirmed that acute volume depletion
enhances fractional and absolute proximal reabsorp-
tion [43, 44].
A number of other variables may also interfere
with or obscure any direct effects of diuretic drugs on
the proximal tubule. Recent studies of Burke and
collaborators [3, 4] have emphasized the role of
changes in whole kidney filtration rate on proximal
reabsorption following administration of furosemide
and ethacrynic acid. In the case of furosemide, altera-
tions in GFR appeared to be related to ECF volume
depletion since replacement of losses prevented a de-
crease in GFR. In this instance proximal fraction
reabsorption was observed to decrease [3]. When
losses were not replaced, GFR fell and fractional
reabsorption was found to increase. Similar increases
in fractional reabsorption could be demonstrated
when GFR was reduced by means of partial renal
artery constriction despite volume replacement. In
comparable experiments performed with ethacrynic
acid, the same laboratory reported that changes in
fractional reabsorption could still be correlated with
changes in GFR despite apparently adequate volume
replacement [4]. Animals showing a severe reduction
in GFR (45 to 64%) showed a significant rise in
fractional reabsorption, whereas fractional reabsorp-
tion fell only in those animals in which there was a
minimal or no fall in GFR. All animals, however,
showed significant increases in absolute and frac-
tional sodium excretion whether proximal fractional
reabsorption had increased or decreased. Brenner et
al (45) have drawn attention to a possible artifact
introduced by retrograde collection of tubular fluid
under diuretic conditions when intratubular pres-
sures are elevated. He showed in the rat that, pro-
vided large oil blocks were placed distal to the punc-
ture site and thus prevented retrograde flow, absolute
reabsorption in the proximal tubule decreased after
furosemide administration. When these precautions
were not taken, a significant degree of contamination
3
Table 1. Major site of diuretic action
Proximal tubule — Carbonic anhydrase inhibitors
— Thiazides
Ascending limb — Furosemide
— Ethacrynic acid
-— Mercurials
Distal tubule and -—Thiazides
collecting duct -—Spironolactone
— Amiloride
occurred which was reflected in falsely high values for
both single nephron GFR and fractional reabsorp-
tion. It is possible that this may account for the
failure of many reported free—flow studies to show
inhibition of proximal reabsorption with furosemide
despite attempts at volume replacement. It must also
be recognized, however, that the attempt to fully
replace fluid losses after furosemide administration
carries with it a danger of overcorrection and some
degree of volume expansion because of the magni-
tude of the diuresis.
In contrast to the somewhat conflicting results of
furosemide under free-flow conditions, almost all ex-
periments designed to test the effects of this drug on
the intrinsic reabsorptive rate of the proximal tubule
have indicated an inhibitory action. Studies in at least
seven laboratories [25, 26, 40, 43, 45-47] have demon-
strated inhibition by the shrinking droplet technique
either after systemic or local administration of the
drug in the peritubular circulation or split droplet.
The in vivo microperfusion studies of Morgan et al
[48] have demonstrated both a reduction in net so-
dium transport as well as an elevation of the
steady—state sodium concentration, The steady—state
chloride ratios have also been found to be signifi-
cantly lower after furosemide [49], suggesting that
steady state bicarbonate concentrations should also
be higher. Radtke et at [26] and Malnic and Giebisch
[20] have also shown a reduction in the rate of prox-
imal hydrogen ion secretion after furosemide admin-
istration, although to a somewhat lesser extent than
after acetazolamide administration, These results are
in keeping with an inhibition of carbonic anhydrase
which has been observed with this drug. In contrast
to the foregoing studies performed under in vivo con-
ditions, recent experiments of Burg et al [50] have
failed to show any inhibition of either net sodium
transport or generation of a negative potential differ-
ence in the isolated rabbit proximal tubule in luminal
concentrations of up to 104M. Peritubular concen-
trations of 103M also failed to alter the electrical
resistance or potential difference of the epithelium.
Grantham [28], however, has reported inhibitory ef-
fects of furosemide when using a modified method of
studying fluid absorption from the isolated rabbit
4 Seely and Dirks
proximal tubule. With this method, one end of the
tubule is closed on itself and the rate of absorption
studied by the rate at which fluid leaves the can-
nulating pipette. It is possible that the composition of
the luminal fluid may resemble more closely that
found under in vivo conditions when using the latter
method, rather than when short segments are per-
fused in vitro, since there may be more time for
changes in perfusate composition to occur. If such
changes are important in determining the net rate of
salt and water transport, this might then account for
the differences observed. It is also possible that in
such experiments secretion of the drug into the l.umen
may osmotically restrict fluid movement apart from
any intrinsic or pharmacological effects. These con-
flicting results make it difficult to draw any firm con-
clusion about the extent of proximal inhibition after
furosemide administration. Some of the data cited do
suggest that salt and water absorption may be inhib-
ited secondary to inhibition of carbonic anhydrase
and that such effects may not be evident with the in
vitro technique used to study the rabbit proximal
tubule. It is clear, however, that the proximal effects
may be easily overcome since, unless extracellular
fluid volume is carefully sustained during the diuresis,
fractional reabsorption actually increases. It is likely
that this occurs in the clinical conditions for which
this drug is used. Nevertheless, as Clapp and his
colleagues have emphasized [3, 4], it is likely that an
inhibitory action in the proximal tubule may reduce
the degree to which fractional reabsorption is in-
creased by any given degree of volume contraction
and, in this sense, may enhance the extent of diuresis
by ensuring a higher degree of delivery out of the
proximal tubule than would otherwise occur.
Ethacrynic acid, which closely resembles furose-
mide in its overall effects on the human kidney, has
been far less studied by micropuncture techniques, in
large part because it is relatively inactive in the rat
compared to furosemide. Nevertheless, the studies
that are available indicate a close similarity of prox-
imal effects. Both Deetjen [51] and Clapp, Notte-
bohm, and Robinson [4] have demonstrated that
ethacrynic acid leads to a reduction in proximal
fractional reabsorption provided volume losses are
replaced and that filtration rate remains constant.
Split-drop studies in the rat [27] failed to show any
significant inhibitory effects.
Mercurial diuretics are almost of historical inter-
est only, at the present time having largely been re-
placed by the more potent oral agents now available.
Experiments in the dog have shown that when vol-
ume losses are not replaced, GFR falls and fractional
reabsorption in the proximal tubule rises [24]. A sub-
sequent experiment from the same laboratory has
shown no further change in fractional reabsorption
when a mercurial diuretic was superimposed on a
modest saline diuresis [52]. These few results suggest
that mercurials do not exert any significant effects on
proximal tubular function. The clearcut effects of
furosemide, ethacrynic acid, and mercurials in the
loop of Henle (see following), in contrast to the prox-
imal tubular studies, give added support to the notion
that different transport systems are involved in these
two segments.
Loop of Henle. Studies of the effects of diuretics
within the loop of Henle have generated far less con-
troversy than their action in the proximal tubule,
reflecting the large degree of agreement between the
results of different laboratories. In this segment, in
particular, studies of isolated perfused tubules have
provided new insight into mechanisms of transport
and of diuretic action. Clearance studies based on
measures of urinary concentration and dilution have
previously pointed to the loop of Henle as an impor-
tant site of action for many of the more potent diuret-
ics. This has been subsequently supported by in vivo
micropuncture evidence of the composition of tubu-
lar fluid as it emerged from the ascending limb into
the distal convoluted tubule. Clapp and Robinson
[53], for instance, have been able to show an increase
in the tubular fluid osmolality of early distal fluid
samples after administration of a number of diuretic
drugs. Other groups subsequently have demonstrated
significant increases in distal sodium and chloride
concentrations in a variety of species following thiaz-
ide, furosemide, and mercurial administration. The
non—reabsorbed fraction of filtered sodium has been
shown to be increased with the latter two despite the
lack of any change in proximal fractional reabsorp-
tion, providing strong evidence for an inhibition of
salt reabsorption within the 1oop itself.
Direct analysis of the effects of diuretics within
loop structures has had to await the development of
techniques for perfusion of isolated segments of the
loop in an in vitro system. Work in two laboratories
with this method has revealed evidence for an active
chloride transport system in the thick ascending limb
of the loop of Henle [54, 55]. This segment has been
shown to generate a small potential difference, lumen
positive, when an identical solution is placed on the
two sides of the epithelium. The potential is abolished
in the absence of chloride and is increased when
sodium is removed from the bathing solution. This
segment is relatively impermeable to water and in the
presence of slow— or stop—flow conditions can gener-
ate hypotonic fluid within the lumen. In this situation
the potential becomes more positive due to the impo-
 Diuretic site of action
sition of a dilution potential for sodiuni chloride
across the epithelium in view of the fact that the
permeability to sodium exceeds that of chloride. In
contrast to the thick ascending limb, both the de-
scending limb and thin ascending limbs of Henle's
loop have not convincingly been shown to be capable
of active transport. The mechanism of osmotic equili-
bration of fluid within the descending limb of Henle's
loop and the role of the thin ascending limb in the
generation of inner medullary hypertonicity remain
controversial, but in any case are secondary to the
action of the thick ascending limb which provides the
ultimate source of energy for urinary concentration
and in part for urinary dilution. It is here that all the
potent diuretics appear to have their major site of
action. Burg and his collaborators have shown that
furosemide [50], ethacrynic acid [56] and the mercu-
rial diuretic, mersalyl [57], are all capable of inhib-
iting both the electrical potential and net solute
transport when applied in low doses to the luminal
bathing medium. It is of interest that these drugs ap-
pear to be far less potent or inactive when presented
to the peritubular side of the epithelium. The ef-
fect of mersalyl could be reversibly inhibited by
p—chloromercuribenzoate, whereas the effect of mer-
curic chloride could not, suggesting that the action of
the mercurial group of diuretics is not simply depen-
dent on the mercuric ion alone. Burg was also able to
show that the ethacrynic—cysteine adduct, in which
form the drug is partly excreted, is active at a far
lower concentration than the native compound. In
view of the preferential action of these drugs from the
luminal side of the membrane, it is relevant that
furosemide is secreted into the lumen of the proximal
tubule and may thus exert an inhibitory action on the
ascending limb when only small doses of the drug are
administered, Interference with the secretion of fu-
rosemide by the organic acid pathway may account in
part for the reason that larger doses of the drug need
to be administered for a diuretic effect in uremic
patients. With the exception of amiloride, which is
inactive in the ascending loop [58], there is no direct
information on the action of other diuretic drugs on
the ascending limb studied in the in vitro system.
Clearance studies suggest that acetazolamide has
little or no inhibitory effects within the loop [59]. A
recent study [41] has demonstrated that net chloride
reabsorption within the loop was increased after ad-
ministration of the carbonic anhydrase inhibitor ben-
zolamide, since fractional chloride delivery rose from
54% to 68% at the end of the accessible proximal
tubule in contrast to a very small change from 4.5 to
6.3% in fractional delivery to the early distal tubule.
This gives further evidence for the lack of an inhib-
5
itory action of this group of drugs on ascending limb
chloride transport.
The action of thiazides in the loop of Henle has
been less clear cut. The results of experiments which
demonstrated no effect on free water reabsorption,
although free water clearance was inhibited, led to
the concept of a "cortical diluting segment" which
was inhibited by these drugs [59]. The exact location
of this site within the nephron, however, was not
defined and could conceivably involve the outer med-
ullary ascending limb of Henle's loop, distal con-
voluted tubule or collecting duct system since in-
ability to generate or maintain hypotonic tubular
fluid within any one of these segments could account
for the impairment in free water clearance. Free—flow
micropuncture experiments in the rat [41] have dem-
onstrated that early distal chloride delivery after
thiazide administration is increased to a very small
extent, compared to the marked increase in end prox-
imal delivery which is very similar to the results seen
after carbonic anhydrase inhibition. If chloride is the
only actively transported anion species in the ascend-
ing loop, this would strongly suggest that this process
is not inhibited by thiazides. Distal TF/P sodium
concentration ratios are found to be increased to a
small extent after thiazides [38], which could result
from the increased delivery of sodium and bicarbo-
nate from the proximal segment to the distal tubule.
Distal convoluted tubule and collecting duct. Studies
of the distal portion of the nephron, distal convoluted
tubule, collecting tubule, and ducts have been rela-
tively hampered more by greater methodological
problems than the more proximal portions. The dis-
tal convoluted tubule is shorter and less easily acces-
sible to the surface for in vivo free—flow studies and
few in vitro studies have been performed on this
segment. The cortical collecting tubules have been
studied by perfusion techniques but are not generally
as accessible for micropuncture as are the medullary
collecting ducts which have also been studied by
microcatheterization techniques. One of the major
problems of studies using free—flow micropuncture
techniques has been the fact that changes in proximal
or loop function may have resulted in different rates
of volume and solute delivery to the distal tubule.
Unless the response of this segment to such changes
in load produced by other means is known, it is
impossible to detect changes in reabsorption due to
diuretic effects from those due to alterations in load,
apart from any other hemodynamic or other effects
of the diuretic on the kidney. Many authors have
surmised that an elevation of the intratubular sodium
concentration in the distal tubule implies an inhibi-
tion of sodium reabsorption both in the loop and
6 Seely and Dirks
distal tubule; however, perfusion studies make clear
that high rates of delivery to the loop alone may
result in high intratubular concentrations of sodium
and chloride. In a free—flow study of the rat distal
tubule, Duarte, Chomety, and Giebisch [60] found
that furosemide almost completely abolished the so-
dium gradient along the distal tubule; however, the
fraction of the filtered sodium reabsorbed along the
distal tubule appeared to be 20 to 30%, which is two
to three times greater than the normal amounts reab-
sorbed in this portion. It seems highly likely that such
apparent increases in absolute sodium reabsorption
in this portion result from the higher delivery and the
low gradient against which sodium must be absorbed.
Morgan et al [48] have studied the effects of furose-
mide on distal tubular function by microperfusion of
the loop of Henle and sequential collections from two
sites in the same distal nephron. They attempted to
control for differences in the loop by providing higher
perfusion rates in the control state to achieve com-
parable flow rates in the early distal tubule. They
were unable to show any significant differences in
reabsorptive rates in control or furosemide—treated
animals; however, the scatter in the results was large
and the concentrations of sodium and potassium
were not equal in the two situations.
Work with carbonic anhydrase inhibitors has con-
firmed that distal hydrogen ion secretion is reduced
[20] and that free-flow distal sodium concentrations
are elevated along with concurrent increases in frac-
tional sodium reabsorption [60, 61]. Wiederholt, Sul-
livan and Giebisch [611 concluded that the increased
load provided additional sodium to undersaturated
distal reabsorptive sites. Recent work of Kunau,
Weller, and Webb [41] presents strong evidence that
thiazide diuretics inhibit the process of sodium and
chloride reabsorption in the distal tubule. The car-
bonic anhydrase inhibitor, benzolamide, in contrast,
had no inhibitory effects on distal chloride reabsorp-
tion. This effect appears to account for the major
natriuretic and chloruretic effect of thiazide diuretics
and probably accounts for the depression of trans-
port in the "cortical diluting segment" identified by
clearance studies.
In contrast to the relative paucity of data regarding
changes ii sodium reabsorption as a result of diuret-
ics in the distal tubule, there is abundant evidence to
suggest that major changes in potassium transport
occur in this segment. Duarte, Chometry and
Giebisch [60] found in their study that whereas early
distal tubular potassium concentrations appeared to
rise following furosemide, late distal TF/P potassium
concentration ratios were equal or lower than con-
trols, yet fractional secretion and urinary fractional
excretion were considerably increased owing to the
high urine flow. They concluded that the effects of
furosemide on potassium transport could be attri-
buted entirely to changes in flow rate along the distal
tubule. The effects of carbonic anhydrase inhibitors
on the distal transport of potassium has been studied
extensively by Giebisch and his collaborators. Studies
of both amphibian and mammalian kidneys have
demonstrated that these agents lead to augmented
potassium secretion [22, 60]. Wiederholt, Sullivan,
and Giebisch [611 suggested that these effects resulted
from enhanced uptake of potassium at the per-
itubular membrane and an increase in the intra-
cellular potassium transport pool.
The action of the mildly natriuretic potassium
sparing agents have received little study by micro-
puncture. The effect of aldosterone within the distal
convoluted tubule and collecting duct has been well
established [62, 63]. In view of the evidence that
spironolactone is a competitive antagonist of
aldosterone and other mineralocorticoids, it is rea-
sonable to expect any future micropuncture studies
under in vivo conditions or in isolated tubules to
support such a distal action.
Amiloride and triamterene, compounds which are
physiologic though not specific antogonists to al-
dosterone, also result in modest natriuresis with re-
duced potassium excretion. During free—flow and
microperfusion studies of the loop of Henle, amiloride
was not found to alter early distal tubular concentra-
tions of sodium or potassium [60] nor has any effect
been observed with this drug in studies of the isolated
ascending limb. However, as expected from clearance
studies, amiloride has marked effects on the distal
convoluted tubule and collecting duct. Duarte,
Chomety, and Giebisch [60] observed a tendency for
distal sodium concentration ratios to rise along the
distal convoluted tubule. This was accompanied by a
small increase (2%) in fractional sodium excretion.
Conversely, the normal increase in potassium con-
centration along the distal tubule was blunted, in-
dicating inhibition of distal potassium secretion and
hence leading to a reduction in urinary potassium
excretion. The mean distal transtubular potential dif-
ference fell from —46 to —26 mV. They considered
that amiloride directly reduced luminal sodium per-
meability, a finding consistent with studies of this
drug on anuran membranes. The recent work of Sto-
ner, Burg, and Orloff on the perfused rabbit cortical
collecting tubule [64] demonstrated that amiloride
rapidly reversed the negative transtubular electrical
potential leading to a small positive potential differ-
ence. Sodium reabsorption and potassium secretion
were also sharply decreased. Further addition of
acetazolamide abolished the positive potential differ-
ence, suggesting the presence of a current of acid-
 Diuretic site of action
ification. The small natriuretic effect compared to the
antikaliuretic effect was attributed to the meagre so-
dium load normally presented to the collecting tubule
but could also reflect the possibility that sodium reab-
sorption is unimpaired by the drug beyond the cor-
tical collecting tubule. Meng [65] has recently con-
firmed, using the split oil droplet technique, that
intraluminal application of amiloride (up to lO-6M)
strongly inhibits isotonic fluid absorption in the distal
convoluted tubule of the rat kidney. Proximal effects
were also seen but only at very much higher concen-
trations.
In conclusion, the availability of many different
diuretic drugs that can selectively inhibit one or more
of a variety of transport processes within the nephron
provides a wide range of options that can be ra-
tionally used in the treatment of edema states and
nonedematous disorders. Caution must be exercised
before the results at a segmental level of the nephron
can be extrapolated to whole kidney in vivo perform-
ance. For instance, hemodynamic effects, changes in
ECF volume, intratubular pressure, tubular fluid
flow rate, or electrolyte composition, etc., may all
exert effects on solute transport independently of any
direct effect of the drug in a particular nephron seg-
ment. Many questions remain unanswered. The ef-
fects of certain diuretics upon proximal tubular trans-
port are still unsettled and the results of in vivo
experiments have not been reconciled with in vitro
in the isolated perfused tubule. The mecha-
studies
nism whereby carbonic anhydrase inhibitors affect
sodium and chloride transport is still unclear as is the
extent to which such effects can account for the prox-
imal action of thiazide diuretics. The answers to these
and many other issues that have been raised by such
studies require much further work and will un-
doubtedly contribute to a better understanding of the
physiology of the kidney.
JOHN F. SEELY
JOHN H. DIRKS
Montreal
Reprint requests to Dr. John F. Seety, Renal and Electrolyte
Division, Department of Medicine, Royal Victoria Hospital and
McGill University, Montreal, P.Q., Canada.
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