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RENAL PHYSIOLOGY 1

Functional renal anatomy Each kidney weighs about 150-200g and is located retroperitoneally just below the

diaphram. The renal artery originates from the aorta to supply each kidney. If the kidney is bisected from top to
bottom, the two major regions that can be visualized are the outer cortex and the inner region referred to as the
medulla. The medulla is divided into multiple cone-shaped masses of tissue called renal pyramids. The base of each
pyramid originates at the border between the cortex and medulla and terminates in the papilla, which projects into
the space of the renal pelvis, a funnel-shaped continuation of the upper end of the ureter. There are one million
nephrons in each kidney. This includes both cortical nephrons which exist out to the periphery (cortex) and the
juxtamedullary nephrons which have are able to create a greater osmolality gradient due to their longer length. The
nephron is made up of a single layer of epithelial cells separated by a basement membrane. The glomerulus
invaginates Bowmans capsule. Fluid is filtered from the glomerular capillaries into Bowmans space under the action
of opposing hydrostatic and oncotic pressures. They are supplied by the afferent arteriole and drained by the
efferent. The filtration barrier to the movement of fluid and solutes into Bowmans space comprises of the capillary
epithelium, a layer of basement membrane, and the capsular endothelial cells, the podocytes. The proximal tubule
collects the large volume of the filtrate from Bowmans capsule and reabsorbs 60% of it back into the blood stream.
The proximal tubule reabsorbs water, sodium, chloride, potassium, bicarbonate, calcium, glucose, urea, phosphate
and any filtered protiens. Substances secreted from the blood into the lumen by the proximal tubule include
hydrogen ions, ammonium, urate and organic anions and cations. The loop of Henle consists of a thin limb which
descends into the medulla, followed by a hairpin turn and an ascending limb which becomes thick as it passes
through the outer medulla on the way to the cortex. The purpose of the loop is to create an increasing interstitual
osmotic gradient in the medulla, permitting reabsorption of water from the from the collecting ducts and production of a concentrated urine (up to 1400 mOsmol/kg) in the presence of ADH. The descending limb reabsorbs water,
the ascending limb reabsorbs sodium, potassium, chloride, and bicarbonate and secretes hydrogen ions. The distal
tubule reabsorbs sodium chloride, bicarbonate, and calcium. Potassium and hydrogen ions are secreted ino the
lumen. There is no exchange of water. The collecting duct is composed of two types of cells: principle and intercalated cells. Aldosterone stimulates sodium reabsorption and potassium secretion by principle cells of the cortical
collecting ducts. ADH increases the permiability of the cortical and medullary collecting ducts to water.

Efferent arteriole
Bowmans capsule
Glomerulus
Afferent
arteriole

Proximal tubule

Arcuate artery
and vein
Juxtaglomerular
apparatus

Distal tubule

Peritubular
capillaries

Renal artery
and vein

Ureter

Cortical collecting
tubule

Loop of Henle
Collecting duct

Cortex
Medulla
Calyx
Papilla
Pyramid
Interlobular arteries
Arcuate arteries

Renal blood flow to the two kidneys is normally about 20 per cent of the cardiac output, or 1100 ml/min. Functional anatomy the renal artery enters the kidney
through the hilum and then branches progressively to form the interlobar arteries, arcuate arteries, and afferent arterioles, which lead to the glomerular capillaries, where
large amounts of fluid and solutes (except the plasma proteins) are filtered to begin urine formation. The renal circulation is unique in that it has two capillary beds, the
glomerular and peritubular capillaries, which are arranged in series and separated by the efferent arterioles, which help regulate the hydrostatic pressure in both sets of
capillaries. High hydrostatic pressure in the glomerular capillaries (about 60 mm Hg) causes rapid fluid filtration, whereas a much lower hydrostatic pressure in the
peritubular capillaries (about 13 mm Hg) permits rapid fluid reabsorption. By adjusting the resistance of the afferent and efferent arterioles, the kidneys can regulate the
hydrostatic pressure in both the glomerular and the peritubular capillaries, thereby changing the rate of glomerular filtration, tubular reabsorption, or both in response to
body homeostatic demands. The peritubular capillaries empty into the vessels of the venous system, which run parallel to the arteriolar vessels and progressively form the
interlobular vein, arcuate vein, interlobar vein, and renal vein, which leaves the kidney beside the renal artery and ureter. Regulation. The main resistors in the kidneys
which modify the flow according to different pressures are the efferent and afferent arterioles. Extrinsically there is both neural and hormonal regulation. The kidneys have
extensive sympathetic innervation and resistance is increased in response to carotid and aortic body stimulation via the medulla to increase resistance in the afferent and
efferent arterioles and reduce flow. The renin angiontensin aldosterone system is also activated in low volume states to retain sodium and water which influences overall
flow along with ADH release. Intrisically the kidney demonstrates autoregulation, maintaining a renal blood flow within a systemic pressure range of 75-170 mmHg. The
intrinsic control of blood flow is mediated by myogenic stretch mechanisms and tubuloglomerular feedback via afferent ateriole constriction. Tubuloglomerular feedback
involves the macula densa which releases adenosine if the renal perfusion pressure rises, and reduces production if the pressure falls. It may also release NO in response to
a decreased perfusion pressure. Measurement The clearance of Para Amino Hippuric acid is used to determine renal blood flow, also using an application of the Fick
principle. PAH is not utilised or excreted by any other organ apart from the kidney, and once filtered or excreted into the tubules it is not reabsorbed. It has an excretetion
ration close to 1.0 therefore the amount excreted is a direct fraction of the plasma filtered (which if the haematocrit is known it can be used to assess renal blood flow).
Tubule function the kidneys produce 150-180L of protein free filtrate per day (125ml/min). The tubules process this filtrate by reabsorbing 99% of the Na and H2O,

conserving essential nutrients (glucose, amino acids etc) and eliminating potential toxins organic bases and acids, excess K, and exogenous compounds. The primary ATP
dependent process in the tubules is the action of the Na.K.ATPase pump. Almost all other transport is via diffusion down gradients or via cotransporters (not shown below).
Tubular reabsorption is regulated by physical and hormonal influences. The first is glomerulartubular balance, which simply states that if glomerular filtration increases,
reabsorption increases. There is also a net resorptive force which represents the tubular starling forces, and the starling forces of the peritubular capillaries. Tubular function is
also under close control of hormonal systems such as the RAAS and parathyroid hormone, and atrial naturetic peptides, and antiduretic hormone.

Proximal tubule - most metabolically


active cells in the kidney, high O2
consumption. Reabsorbs 60-70% Na+ and
H2O. Complete reabsorption of amino
acids and glucose (cotransported with
Na+). Almost complete reabsorption of
HCO3- and excretion of H+ through
carbonic anhydrase catalysing the
reaction between carbon dioxide and
water. Phosphate is also reabsorbed here.
Descending loop of Henle. The cells of
the thin descending limb do not carry
out active transepithelial ion transport
but act as important passive equilibriators in the process of countercurrent
multiplication.

Proximal Tubule

H+

Na+

2K+

CO2 + H2O

Distal Convoluted

3Na+

Na

HCO3-

2K

Cl-

Amino acids,
Phosphate

Ca++

Glucose
H2O / NaCl

Tubule
Lumen

Interstitual
Fluid
Principle Cell

Descending loop
of Henle

Na+
Tubule
Lumen

3Na+

Interstitual
Fluid

2K+

3Na+

K+

Intercalated Cell

Thick ascending loop of Henle is


involved in extensive transepithelial
reabsorption of Na+ - up to 25% of total,
and chloride, with smaller fluxes of K+,
Mg++ and Ca++. It is impermiable to water
under all conditions and this allows the
countercurrent to be established. This is
where loop diuretics (frusemide) work

Christopher Andersen 2012

H+
Thick ascending
loop of Henle

Na+
ClK+
K+

2K+

3Na+

ClK+
Na+, K+, Ca++, Mg++

HCO3ClH2O

Distal convoluted tubule is a morphologically


and functionally heterogenous segment that
extends from the macula densa to the early
branching of the CCT. Sodium is reabsorbed
with chloride but there is little K+ or H2O
movement. Ca++ reabsorption occurs
modulated by parathyroid hormone. Thiazides
act here and enhance Ca++ reabsorption

Cortical collecting duct is the final fine


tuning of the urine output. There is
reabsorption of some 2-3% of filtered Na+
load, Cl- reabsorption, K+ (principle cell)
and acid excretion (intercalated cell). All of
these processes are stimulated by
aldosterone. Water permiability is variable
and dependent on ADH creating
aquaporins. Amiloride and spironolactone
act here and cause sparing of potassium
and acids.

RENAL PHYSIOLOGY 2
Glomerular filtration and measurement Glomerular filtration is one of the key steps in the function of the kidney. The glomerulus is a specialised capillary bed with
two important characteristics. Firstly it is located between two arterioles. This means that it is able to operate at higher pressures then normal capillary beds, and that
variations in either the afferent or efferent branches creates variable pressure differentials which will increase or decrease the hydrostatic pressure within the glomerulus
also acting as the effector of autoregulatory mechanisms. Secondly, it has very high permiability which decreases as molcule size increases from 7kDa (very little albumin is
filtered as it is 70kDa), which is a function of the capillary epithelium, a layer of basement membrane, and the capsular endothelial cells (podocytes). The permiability is
quantified by the ultra-filtration coefficient Kf. What ultimately determines glomerular filtration is the product of the filtration coefficient and the net starling forces (also
known as the net filtration pressure). It is important to note that because limited large molecules are filtered their is negligable oncotic pressure towards Bowmans Space,
therefore the net filtration pressure is the sum of the opposing hydrostatic pressures minus the oncotic pressure towards the plasma. It should also be noted that there is a
slight negative charge on the glomerular membrane and that this predisposes to positive ions being filtered. The percentage that is filtered at the glomerulus may be
quantified by the filtration fraction (FF) and is usually 15-20% renal plasma flow (RPF). Measurement Renal clearance is the volume of plasma completely cleared of a
substance by the kidney per unit time (similar definition to liver). This can be represented by the formula; Clearance = UV/P where U is the urine concentration, P is the
plasma concentration and V is the volume of urine produced per unit time. A substance which is filtered at the glomeruli, and neither reabsorbed or secreted by the tubules
will represent the glomerular filtration rate. Inulin, a plant polysaccharide is often quoted as the best candidate but the measurement is problematic because the substance
is exogenous and requires a steady state scenario to give an effective measurement. Creatinine, a byproduct of creatine breakdown in the muscles is an endogenous
alternative. A small amount is secreted by the tubules into the lumen although this is often evened out by overestimation is the measurement of plasma creatinine.
Creatinine varies significantly with muscle bulk and therefore it is often corrected for these age, weight and sex by formulas such as the Cockroft-Gault. There is also a non
linear relationship between serum creatinine and creatinine clearance. There can be a decline of almost 50% of renal function before there is a significant increase in serum
creatinine.
The countercurrent mechanism relates to a physiological process which sets up a concentration gradient from the cortex through to the medulla. Countercurrent mechanism is based on several assumptions
1) No flow of water in the ascending limb of the loop of Henle
2) Active transport of solutes out of the ascending loop of Henle creating gradient of 200mOsmol across the membrane
3) Urea from the cortical collecting duct augments the concentration in the medulla (650 of the 1400mOsmol total)
4) The vasa recta is organised such that it does not wash away the interstitual medullary gradient
The final concentration is dependent on the length of the loop, the capacity of the active pumps in the thick ascending limb and the rate of flow through the tubules
and a maximum figure of 1400mOsmol is usually quoted. The result of this physiological process is the kidney is able to concentrate urine up to a concentration 1400
via ADH induced reabsorption of water in the cortical collecting duct. A simplified model is shown below.
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300 400

UREA

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UREA

300 125

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6 00

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UREA

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UREA

1200

Initally, sodium is transported


from the ascending loop to
the interstitium

Water is then removed


osmotically to the interstitium
to balance the concentrations

Step one again, as


solute is removed the intratubular concentration drops

Step two again, the medullary


concentration increases with
urea augmenting the process

1200

After the process occurs multiple


times the final concentrations are
set as shown.

Endocrine functions of the kidney may be divided into three separate categories. The first of these categories is hormones
produced by the kidney this includes calcitriol, erythropoietin and prostaglandins. Calcitriol, also known as 1,25 dihydroxycholecalEnzymes related
ciferol is the final step in the activation of vitamin D, it is initially formed by the skin, the first step in activation occurs in the liver and Hormones
to hormones
Produced
the final activation in the kidney. It is involved in the regulation of calcium, in particular the absorption from the gut, the reabsorprenin
calcitriol
tion in the kidneys and action on the bones. Erythropoeitin is is a glycoprotein synthesized in response to arterial hypoxemia, and it
kallikrein
erythropoeitin
stimulates RBC production in the bone marrow. Prostaglandins are unsaturated fatty acids containing 20 carbon atoms and a
prostaglandins
five-membered carbon ring at one end. In addition to the kidneys they are synthesised in most tissues from arachidonic acid and
have a multitude of roles. The second category are the enzymes released by the kidney which directly contribute to the production
and release of hormones. Renin is released from the juxtaglomerular aparatus in response to decreased renal perfusion and through
Hormones which act
a number of steps forms angiotensin I and II and stimulates the release of ADH and aldosterone. Kallikreins are serine proteolytic
on the kidneys
enzymes in plasma and tissue which produce kinins from kininogens, such as bradykinin which has important circulatory effects
antidiuretic hormone
including vasodilation and increased vessel permiability. The final category is hormones which have there site of action at the
aldosterone
kidneys - antidiuretic hormone, aldosterone, calcitriol, parathyroid hormone & atrial naturetic peptide. Anti diuretic hormone
calcitriol
increases water loss in the CCD via aquaproins. Aldosterone acts on the distal tubule and the CCD to exchange hydrogen and
parathyroid hormone
potassium from salt and water. Parathyroid hormone increases calcium reabsorption from the distal tubule. Atrial naturetic peptide
atrial naturetic peptide
is produced by the right atrium in response to increase blood volume and this causes an increased secretion of sodium from the
kidney. The mechanism is not well understood.
Kidney acid-base functions daily acid production is greater than 500 moles, but most of this is instantly turned over in reactions such as ATP and mitochondrial
activity. The net production represents the excess production and is divided into the volatile component and fixed or non-volatile component. The volatile component is
derived from the metabolism of fats and carbohydrates which produce CO2 and H2O - the former of which is removed by the lungs (roughly 12-15 moles per day depending
on metabolic demands). The non-volatile or fixed component is derived from a range of different sources and is immediately neutralised via the bicarbonate buffering
system and is removed from the body via the kidneys (roughly 0.1-0.15 moles per day). The kidneys role in acid base functions is to excrete an amount of acid equal to the
non volatile acid production and in doing so replenish the the HCO3- by both reabsorption (mostly in the proximal tubule and thick ascending limb) and formation of new
bicarbonate (mostly as a byproduct of phosphate buffering). Quantitatively the reabsorption of the HCO3- is more significant with the amount filtered at the glomerulus
around 4300 mEq/day with only approximately 100mEq/day required per day for non volatile acid balance. As there is ultimately a net excretion of acid urine generally has a
low pH. Urine is usually no more acidic than pH 4, and this equates to a total H+ only 0.1 mEq/day. The work around for this is through titratable acids which is the collective
term for urinary buffers (of which phosphate is the most important) and the excretion of ammonium. From this understanding we can see that the actual net acid excretion
(which is equal to the non volatile acid production) may be represented by the formula
Net Acid Excretion = titratable acid + ammonium - HCO3- loss.
Acid secretion is regulated by a number of different factors including endothelin and cortisol which are released in response to acidosis and increase the transcription of
transporters that facilitate acid transport from the apical membrane. Aldosterones primary action is on the DCT and CCD to stimulate Na+ reabsortion and as a side effect
increase intercalated cells H+ release. Parathyroid hormone acutely inhibits H secretion (by blocking the Na+-H+ antiporter) and in the long term stimulates H excretion in the
TAL of the loop of Henle. Potassium regulates the system, hyperkalaemia inhibits H+ secretion and hypokalaemia stimulates H+ secretion.

Christopher Andersen 2012

RENAL PHYSIOLOGY 3
Body water homeostasis refers to the overall balance of fluid intake and output. This includes all body water in both the extra
and intracellular compartments (44L in 70 kg man). The system for maintaining this homeostasis may be considered a simple control
system with sensors, a central controller and effectors. The most important sensor is the osmoreceptors located in the hypothalamus. It follows that the osmolality is the key determinant in maintaining total body water balance, a net increase in total body water
will lead to a decrease in osmolality and a decrease in TBW will lead to an increase. The main molecule responsible for osmolality is
sodium, hence its primacy in our appreciation of diuretic actions. Other sensors are more specialised and are determined by
pressure and volume only on the related intravascular compartment, these include the low pressure sensors located in the right
atrium and veins and the high pressure sensors in the aortic arch and carotid sinus. These augment the response, (and have other
actions such as stimulating renin release from the kidney and causing vasoconstriction and increased TPR in low pressure states as
well as the release of atrial naturetic peptide and brain naturetic peptides in high volume states). The central controller is the
hypothalamus. The effectors are thirst and antidiuretic hormone. Anti diuretic hormone is a naturally occuring peptide released from
the posterior pituitary also known as vasopressin. In addition to the main driver of release which is osmolality and the augmenting
effects of the intravascular sensors (responding to hypovolaemia and hypotension) ADH is also released in response to stress. ADH
acts on GPCR located on smooth muscle, platelets and importantly on the distal convoluted tubule and cortical collecting duct (V2
receptors). Because of the countercurrent mechanism setting up a large osmotic gradient in the medulla of the kidney the V2
receptors in the DCT and more so in the CCT are able to increase water reabsorption through activation of water channels called
aquaporins. This enables urine to be concentrated to up to 1400 mOsmol and become as dilute as 50-100 mOsmols in the setting of
hypervolaemia. Thirst is the physiological urge to drink. It is usually unneccesary because of hedonistic water intake due to social
and behavioural factors, but can be a potent back up mechanism if intake due to hedonstic factors is insufficient.
Glucose handling glucose is completely reabsorbed in the proximal tubule by co-transport with sodium ions. at concentrations below 12mmol/L. The proximal tubule
resorbs all of its glucose in the tubular fluid. However, the specific carrier mechanism for glucose can be overloaded as the proximal tubule has a transport maximum for
glucose (and other nutrients). If the filtered load exceeds the proximal tubule transport maximum, as may occur in DM, glucose appears in the urine. In humans, at a
normal GFR of 125mL/min, glucose begins to appear in the urine at a plasma glucose concentration of 10-12 mmol/L and becomes saturated at 15 mmol/L.

Urea and creatinine handling The liver produces urea in the urea cycle as a waste product of the digestion of protein (50g per day). Urea is

passively reabsorbed
from the tubule. As water is reabsorbed from the tubules (by osmosis coupled to sodium reabsorption), urea concentration in the tubular lumen increases. This creates a
concentration gradient favoring the reabsorption of urea. However, urea does not permeate the tubule as readily as water. In some parts of the nephron, especially the
inner medullary collecting duct, passive urea reabsorption is facilitated by specific urea transporters. Yet only about one half of the urea (25g) that is filtered by the
glomerular capillaries is reabsorbed from the tubules. The remainder of the urea passes into the urine, allowing the kidneys to excrete large amounts of this waste product
of metabolism. Another waste product of metabolism, creatinine (2g per day), is an even larger molecule than urea and is essentially impermiable to the tubular
membrane. Therefore, almost none of the creatinine that is filtered is reabsorbed, so that virtually all the creatinine filtered by the glomerulus is excreted in the urine.

Renal excretion of drugs and metabolites in the urine involves three distinct processes: glomerular filtration, active tubular secretion, and passive tubular reabsorption. Changes in overall renal function generally affect all three processes to a similar extent. Almost all drugs are filtered at the glomerulus. Filtration is directly related to
the rate and unlike the liver it is possible to estimate filtration rate using the cockroff-gault formula or eGFR. If a drug is in a lipid soluble form during its passage down the
tubules a significant portion will be reabsorbed by simple passive diffusion. It may be therefore advantageous to have a drug in its ionised form which will increase removal
of a drug in an overdose situation or non inonised form to extend its duration by alkanising or acidifying the urine. Pancuronium is the only anaethetic extensively
execreted renally.
Physiological response to acute renal failure

Symptoms of acute renal failure are not detected until less than 40% of normal functioning nephrons remain, and
uraemic symptoms do not occur until less than 5% of normal functioning nephrons remain. Acute renal failure is attributed to several mechanisms (1) diseases that cause
renal hypoperfusion, resulting in decreased function without frank parenchymal damage (prerenal ARF, or azotemia) (~55%); (2) diseases that directly involve the renal
parenchyma (intrinsic ARF) (~40%); and (3) diseases associated with urinary tract obstruction (postrenal ARF) (~5%). Typically an early compensatory phase of normal renal
adaptation progresses to ARF. Depending on renal function reserve this may occur over a period of hours to days. At this point the decline in renal function results in the
retention of nitrogenous and end products of metabolism and an inability to maintain fluid and electrolyte homeostasis. Physiological responses to the most common
cause of ARF (hypoperfusion) are as follows. In states of mild hypoperfusion, glomerular perfusion and the filtration fraction are preserved through several compensatory
mechanisms. In response to the reduction in perfusion pressure, stretch receptors in afferent arterioles trigger afferent arteriolar vasodilatation through a local myogenic
reflex (autoregulation). Macula densa sensors in the juxtaglomerular feedback mechanism sense a decrease in sodium delivery and release renin, as well as augment the
dilation of the afferent arteriole. Angiotensin II increases biosynthesis of vasodilator prostaglandins (e.g., prostaglandin E2 and prostacyclin), and induces preferential
constriction of efferent arterioles. As a result, the fraction of plasma flowing through glomerular capillaries that is filtered is increased (filtration fraction), intraglomerular
pressure is maintained, and GFR is preserved. The renin release also which increases total body water via the RAAS (but may be blocked by medications already). With more
severe hypoperfusion, these compensatory responses are overwhelmed and GFR falls, leading to prerenal ARF.

Christopher Andersen 2012

Christopher Andersen 2012

ACID BASE PHYSIOLOGY


Terminology

Acids have been defined in a number of ways (initially from the latin sour). Arrhenius theory describes an acid as a substance which dissociates in water to
produce hydrogen ions. Bronsted-Lowry defined an acid as a substance which donates a proton and the substance which accepts the proton is the conjugate base. This is the
most commonly used definition in biological sciences. Note that CO2 is not a B-L acid but represents the potential to be an acid via combination with H2O to form carbonic
acid, and is often therefore called an acid regardless. There are two main approaches to interpreting acid base physiology. The conventional approach and the physicochemical approach first described by Stewart.

Conventional approach Analysis based on the interactions of hydrogen ions,


bicarbonate and carbon dioxide. Underpinned by the Henderson-Hasselbach
equation which is based on the law of mass action. Overall the daily production
and consumption of hydrogen ions is very large due to processes such as ATP
turnover and mitochondrial activity (>500 moles). The net production requiring
either excretion from the lungs (volatile - 12 moles) or from the kidney (fixed - 0.1
mole) is much smaller but of significant physiological importance. In the
conventional approach it is the interaction of the hydrogen ions which determine
the pH, the bicarbonate which is the most important buffer in the system and is
regulated by the kidney and the pCO2 which is regulated by the respiratory system
which determine the physiological acid-base state. The benefits of this system is
that it can be applied clinically to assess patient acid base status based on their
history, the severity of the disorder and identify mixed disorders.

RESPIRATORY SYSTEM
Excretion of volatile
acid (CO2)

LIVER
Net producer of H+ or
Net consumer of H+

RENAL SYSTEM
Reabsorption of HCO3Excretion of fixed acids (H+)

Stewart Approach Developed using the physicochemical laws including the

law of mass action, law of electroneutrality, and the conservation of mass.


Stewart characterised 3 independent variables. The total weak acids (ATOT), which
is the sum of all weak acids (by definition are incompletely dissociated). It is often
simplified when considering the IV compartment to albumin which predominates. The amount of albumin is determined by the liver (therefore independent).
The second independent variable is the pCO2, which is controlled by the resp
system. The final variable is the strong ion difference (SID) which is the difference
between the completely dissociated cations (Na+, K+, Ca++, Mg++) and anions (Cland other anions). It is often simplified to Na+ - Cl- and is usually around 40-45. It is
determined by the kidneys and to a lesser extent GIT system. Using the three
independent variables it is possible to determine the dependent variables which
include [H+], [HA], [A-], [OH-], [HCO3-], using a 4th order polynominal equation to
solve for the six physicochemical laws (which include the henderson-hasselbach).

RESPIRATORY SYSTEM
Excretion of CO2
Determines pCO2

LIVER
Producer of weak acids
Main determinant ATOT

RENAL SYSTEM
Excretion of Cl- and
other strong ions
Main determinant SID

Importance of pH. There are two main reasons why pH is so important. The first is the Davis hypothesis and relates primarily to small molecules.

This states that many


biologically significant compound are completely ionised near neutral pH and therefore are trapped within the cell and its organelles. The second reason relates to larger
protiens which maintain optimal performance at a specific pH intra cellularly and extracellularly. We usually required to infer the ICF pH from ECF measurements when
attempting to maintain this optimal pH level. This becomes somewhat fraught in the setting of changing temperatures because as the temperature drops the CO2 becomes
less soluble (and therefore the pH increases). Some teaching supports correcting the plasma pH back to its value at 37 degrees (7.4) by adjusting the system (adding more
CO2) this is the pH stat approach. What has been found experimentally however is that imidazole groups intracellularly remains ionised (alpha) at a constant amount
regardless of temperature, therefore ICF pH remains near neutrality (6.8) despite temp changes. This approach advocates accepting that plasma pH will vary with temp
(usually by 0.015 pH units per degree) but this will not affect the ICF pH. Alpha stat is more accepted.

Buffering a buffer is a substance with the capacity to bind or release H+ and thus minimise changes in pH. Buffers consist of a mixture of a

Red Blood Cells


haemaglobin
bicarbonate

Plasma
Bicarbonate
Proteins

weak acid and its conjugate base. A buffer is most effective at its pKa, at which it is 50% ionised. Most of the buffering capacity in the body
occurs in a narrow range of pH. The effectiveness of a buffer in a physiological system is also dependent on if it is open like the bicarbonate
system where CO2 may be removed via the lungs or closed (chemical). Buffering may occur for a target pH of 7.4 which is the pH of the ECF
pH 6.8
pH 7.4
or 6.8 which is the pH of the ICF. RBCs are usually considered in the ECF category due to its importance as a buffer in this compartment.
ICF
ISF
protien
The major buffer system in the ECF is the CO2-bicarbonate buffer system. This is responsible for about 80% of extracellular buffering. It is the
Protien
phosphate
most important ECF buffer for metabolic acids but it cannot buffer respiratory acid-base disorders. The components are easily measured and
bicarbonate
are related to each other by the Henderson-Hasselbalch equation. pH = pKa + log10 ( [HCO3] / 0.03 x pCO2) The pKa value is dependent on
the temperature, [H+] and the ionic concentration of the solution. It has a value of 6.099 at a temperature of 37C and a plasma pH of 7.4. On
chemical grounds, a substance with a pKa of 6.1 should not be a good buffer at a pH of 7.4 if it were a simple buffer. The system is more complex as it is open at both ends
(meaning both [HCO3] and pCO2 can be adjusted) and this greatly increases the buffering effectiveness of this system. The excretion of CO2 via the lungs is particularly
important because of the rapidity of the response. The adjustment of pCO2 by change in alveolar ventilation has been referred to as physiological buffering. Protein buffers in
blood include haemoglobin (150g/l) and plasma proteins (70g/l). Buffering is by the imidazole group of the histidine residues which has a pKa of about 6.8. This is suitable for
effective buffering at physiological pH. Haemoglobin is quantitatively about 6 times more important then the plasma proteins as it is present in about twice the concentration and contains about three times the number of histidine residues per molecule. The phosphate system HPO4-2 and H2PO4- has a pKa of 6.8 and so has a theoretic
advantage over bicarbonate. It only exists in very small concentration in the ECF however and is a closed system so makes minimal contribution. It is however a significant
buffer in the ICF.

Regulation of the Acid-Base

There are two major systems which regulate acid base physiology and several lesser contributors. The first is the respiratory system.
Important characteristics are; CO2 is the only acid excreted by the lungs, this excretion is very rapid and the system is high capacity compared to the kidneys (15 moles vrs
0.1 moles). The control of the system is based on central chemoreceptors which rely on CO2 crossing the BBB and increasing local [H+] which is relayed to the respiratory
centre in the medulla to alter ventilation and therefore the pCO2. This is augmented by the peripheral chemoreceptors in the aortic arch and carotid bodies. These sense
changes in pO2, pCO2 and pH, and therefore are very important in a metabolic acidosis providing the stimulus for respiratory compensation (H+ does not cross the BBB
therefore the central chemoreceptors do not play a role). The other main system is the renal system which is involved in the excretion of fixed acids is the distal tubule and
the reabsorption of bicarbonate in the proximal tubule. It is the balance of these two processes which determines the kidneys response to changes in pH (in alkalosis less
HCO3 is reabsorbed and H excreteted, in acidosis the oppostie). The renal response is influenced by the pCO2, the pH, the bicarbonate level, ECF volume, angiotensin,
aldosterone and hypokalaemia. Minor regulation takes place by the bones (in persistent metabolic acidosis as a source of CaCO3 for buffering) and the liver as a net
producer or consumer of hydrogen ions through metabolic processes.

Analysis of blood gas .A deranged pH is responded to by the body in three ways, buffering, compensation and correction. The most important aspect to
assessment is a clinical history, especially regarding the chronicity (and therefore opportunity for appropriate compensation).
Respiratory Acidosis

Definition: is a primary acid base disorder in which


arterial pCO2 rises to a higher level than expected
Causes: Most due to decreased alveolar ventilation,
others are increased inspired CO2 or CO2 production
Effects: (increased CO2) increased ventilation, cerebral
vasodilation, SNS activation, tachycardia, decreased
intracellular metabolism and central depression at high
levels
Acute buffering: intracellular buffering with Hb leads to
increase in HCO3 Expected HCO3= 24+1(pCO2/10)
Chronic compensation: is renal retention of HCO3
which is slower >6hrs and leads to a more pronounced
correction, pCO2 Expected HCO3= 24+4(pCO2/10)
(outside expected = mixed disorder).
Correction: Increase ventilation

Respiratory Alkalosis

Definition: is a primary acid base disorder in which


arterial pCO2 decreases to a level less than expected
Causes: Always due to increased alveolar ventilation
Effects: (decreased CO2) cerebral vasoconstriction adn
associated short term ICP drop, arrhythmias, decreased
myocardial contractility, increased neuromuscular
irritability, decreased respiratory drive, Hb-O2 curve left.
Acute buffering: Intracellular and plasma protiens, leads
to decreased HCO3 Expected HCO3= 24-2(pCO2/10)
Chronic compensation: is renal loss of HCO3 which is
slower >6hrs and leads to a more pronounced
correction, pCO2 Expected HCO3= 24-5(pCO2/10)
Correction: treat precipitant (lung pathology causing
sensation of dyspnoea (PE, asthma, pneumonia),
anxiety.

Metabolic Acidosis

Definition: is a primary acid base disorder leading to an


increase in fixed acids in the blood.
Causes: Classified by the anion gap = [Na] - [Cl ] - [HCO3]
normally 8-16. Normal AG include renal tubular
acidosis, diarrhoea, addition of Cl ions. Increased AG
causes include ketoacidosis, lactic acidosis, renal failure,
toxins (incl. ethylene glycol, methanol, salicylates).
Effects: Hb-O2 curve right, decreased 2,3DPG (Hb-O2
curve left), incr resp rate (Kussmaul), decreased
myocardial contractility, SNS activation, decreased
catecholamine sensitivity, K shift out of ICF (inc K lvls) .
Acute buffering: via HCO3 causing sharp drop according
to formula Expected pCO2 = 1.5(actual [HCO3] +8)
Acute compensation: increased respiratory rate
Correction: correct cause, renal and liver HCO3
production

Metabolic Alkalosis

Definition: is a primary acid base disorder leading to an


overall increase in bicarbonate in the blood.
Causes: loss of H+ (Cl- in Stewart) from the kidney
(diuretics) or gut (vomiting, NG tube - 90% total) or
increased HCO3, citrate in blood, sodium bicarb IV,
adrenocortical excess syndromes.
Effects: Decreased myocardial contractility, decreased
cerebral blood flow, confusion/obtundation,
neuromuscular excitability, Hb-O2 shift left.
Hypokalaemia can be life threatening
Acute compensation: decreased respiratory rate
Expected pCO2 = 0.7(actual [HCO3] +20) (+/- 5)
Correction: Treat precipitant and the maintaining
process (without which the kidney usually corrects the
system quickly by excreting bicarb). Give oxygen!
Replace chloride and potassium.

FLUIDS AND ELECTROLYTES


Distribution of body fluids The distribution of body fluids is considered from a conceptual perspective.

ADULT MALE WEIGHT 70kg


40%

40%

TISSUE
COMPONENTS
>OBESE & ELDERLY
<INFANTS

20%

ICF 28kg

ECF 14kg

OTHER CELLS
26 kg

ISF
11kg

RBC 2kg

There are two principle body fluid compartments, the intracellular compartment (ICF) which is approximately
40% of weight and the extracellular compartment (ECF) which consists of approximately 20% total weight
(total body water TBW = 60%). The ECF is further subdivided into fluid which is intravascular (the plasma
volume) which is about 4-5% TBW and the interstitual fluid (ISF) which is about 15-16%). The ratio of non
fluid tissue components to fluid compenents varies with age, sex and body habitus. Neonates and infants
have a much higher TBW (up to 80%) mostly increased extra cellular fluids. Fat tissue has substantially less
water content therefore women have a slightly lower TBW, and obese people may have a markedly decreased
TBW. The elderly also have decreased TBW.

PV 3kg

Measurement of fluid compartments

This is based on the conservation of mass laws. Rearranging the equation concentration
Fluid
= amount/volume gives the formula volume = amount/concentration. Therefore if it is possible to add a known amount of solute to a
Marker
Compartment
solution, which mixes evenly and completely and remains in the single compartment, then measure the resultant concentration we
can apply this formula to calculate the volume. Total body water may be measured using known amounts of isotopically labelled water TBW
Deuterium 2H
such as deuterium 2H or tritium 3H which disperses throughout the whole body and is measurable using nuclear medicine techniques.
Mannitol/Ionics 33Br
ECF
Other compartments are more difficult to measure. The ECF markers must cross capillaries easily but not cell membranes and a
Evans Blue / RISA
Plasma
common example is mannitol or inulin which are large molecule that cannot cross cell membranes and therefore is excluded from the
33
Cr labelled RBCs
RBCs
ICF. Other methods for measuring ECF involve isotopically labelled berrellium. Evans blue is a dye that binds to albumin and thus
Interstitual ECF - PV
remains intravascularly (an alternative is radio iodinated serum albumin RISA). It may be measured and correcting for the RBC volume
TBW - ECF
ICF
using haematocrit enables calculation of the PV. Interstitual volume is measured indirectly by the formula ECF - PV. ICF is calculated by
the formula TBW - ECF. The main issue with all these methods is the assumptions involved. They often do not remain solely within a
single compartment, nor do they always mix completely.

Definitions

is the number of moles of solute per kg of solvent (one mole of a substance = 6 x 1023 particles)
Molarity
movement of solvent across a semipermiable membrane until the concentration of solution on both sides is equal
Osmosis
Osmotic Pressure pressure required to prevent movement of solvent molecules by osmosis across a semipermiable membrane = nRT/V (ideal gas law)
Oncotic Pressure (colloid osmotic pressure) is the compenent of total osmolality which is due to colloids MW>30000, Albumin (75%) globulin & fibrinogen
one osmol equals 6 x 1023 particles regardless of the type of particle present (also the amount of substance that would depress freezing
Osmol
point by 1.86K - a colligative property)
is the number of osmols of solute per kg of solvent and is independent of temperature
Osmolality
is the number of osmols of solute per litre of solvent and is dependent on temperature (the liquid may expand and increase volume)
Osmolarity
is the effective osmolality of a solution (some of the solute may not stay in the extracellular compartment (eg urea) and is discounted)
Tonicity
Reflection coeff The reflection coefficient represents the capillary permiability to albumin, with 0 being freely permiable and 1 impermiable.
Colligative prop Are the properties that are dependent on the concentration of the particles

Osmotic pressure may be calculated using a derivation of the ideal gas law (called vant Hoffs law here). PV = nRT where Osmotic Pressure = P, V equals the volume, n
= number of osmols, R is the gas constant 62.3 (using mmHg 0.082x760) and T is the temperature in Kelvins. Since the number of osmols/volume = concentration it may
be expressed as P = CRT. If the concentration is 1 osmol per litre (osmolalrity = 1) then the osmotic pressure is 19300 mmHg (milliOsmols = 19.3). Therefore for every
mOsmol increase in concentration gradient across the cell membrane there is a 19.3 mmHg increase in osmotic pressure. For normal plasma the osmolality is 285
mOsmol, from this we can calculate the osmotic pressure of the plasma as 19.3 x 285 = 5500 mmHg (over seven atmospheres!).
PV
P
P
P
P
P
P

=
=
=
=
=
=
=

nRT
CRT
1(62.3)(310)
19300 per Osmol
19.3 per mOsmol
19.3(285)
5500mmHg

P = osmotic pressure
V = volume in Litres
n = number of Osmols
R = Gas constant (62.3 if using mmHg)
T = Temperature in Kelvins
n/V = C = Osmolarity
assume osmolality is 285

Plasma oncotic pressure

is the osmotic pressure exerted by the colloids which are the large non permiable particles in the intravascular space, mostly albumin and
other significant protiens. They only exert about 25-30 mmHg of the total osmotic pressure (<1% of 5500) but are very important in terms of the starling forces, they are
the only effective solutes exerting force to retain water in the capillaries and therefore maintaining circulating volume. The reflection coefficient represents the capillary
permiability to albumin, with 0 being freely permiable and 1 impermiable. Normally it is 0.6-0.9. The more permiable the less oncotic pressure the albumin exerts in the
calculation of starling forces - Filtration = capillary filtration coefficient(hydrostatic pressure difference) + reflection coefficient(colloid oncotic pressure difference).
OSMOTIC GRADIENT
ELECTROCHEMICAL GRADIENT

Gibbs-Donnan effect situation created with a semipermiable membrane. Some ions (eg Na+ and Cl-) freely move but others

(eg large anion proteins) dont. More Na will exist on the side with the large anions and more Cl on the other side to ensure
chemico-electrical equilibrium. Despite electrical equilibrium there is now osmotic disequilibrium and water will move into the
intravascular side (disrupting the chemico-electrical state). The result is opposing osmotic and electo-chemical gradients. As a
result of increased osmols on the intravascular side, there is an augmentation of the plasma oncotic pressure. This is also very
important for the stability of the cell volume where the cell membrane is also semipermiable and intracellular proteins and organic
phosphates cause a donnan effect into the cell and the extrusion of increased cations by the Na-K-ATPase pump cause a reverse
donnan effect (double donnan). It makes a small contribution to the resting membrane potential.
+

Large
Anion

+ Na+

+
-

- Cl-

Measurement and regulation of osmolality Osmolality is measured in the hospital setting by an osmometer which uses the colligative properties of a fluid

(those dependent on the particle concentration) to calculate osmolality. This is done in two main ways, through freezing point depression or vapour point depression.
Osmolarity may be estimated using the formula Osmolarity = 2(Na+) + blood glucose + blood urea. An osmolar gap is the difference between the measured osmolality
and the estimated osmolarity and is usually less than 10. This gap may be increased if there are alcohols, sugars or contrast mediums. Hyperosmolar states exist where
there is raised urea, hyperglycaemia or hypernatraemia. Overall osmolality is regulated in the body by the osmol receptors in the hypothalamus which sense changes of
as small as 1-2% and increase or decrease vasopressin (ADH) secretion from the posterior pituitary accordingly. At a cellular level cells manage changes in osmolality by
increasing the influx of solute (usually by ions which will interfere with metabolism) and/or producing indogenic solutes which have minimal effect on metabolism. The
second mechanism is particularly important in the brain which uses the idogenic molecules to draw water in to restore cellular volume. It is why the barin tolerates
chronic hypo-osmolar states much better than acute hypo-osmolar states.

Lymph is the name given to interstitual fluid which enters the lymphatic system. Lymphatic capillaries are present in almost all tissues with the exception of bone,

cartilage and the CNS. Up to 3L of fluid is lost per day from the ISF and if this was not recovered by the kymphatic system this would lead to hypovolaemia. This fluid
travels from the blind ended lymphatic capillaries into larger lymphatics and eventually into the thoracic duct and then into junction of the subclavian and and internal
jugular veins. In addition to the fluid recovery function, lymph also returns protien from the ISF, transports fat from the small intestine and performs important
immunological functions such as a transport method for lymphocytes and macrophages, a transport method for antigenic material to be presented to dendritic cells
and lymph nodes, and for the dissemination of cytokines. Lymph consists of the ISF (with a lower concentration of protiens than plasma), lipids from the small intestine
such as fatty acids, triglycerides, chylomicrons (these lipids gives the milky composition of chyle), lymphocytes and macrophages.

Christopher Andersen 2012

FLUIDS AND ELECTROLYES 2


Sodium is the principle extracellular cation. It is present in the ECF at a concentration of about 140 mmol/L. There is small increase in amount of sodium on the
plasma side compared to the ISF of about 6-7 mmol due to the Gibbs-Donnan effect but the measured levels are usually very similar because the plasma solid
effect reduces the measured amount in the PV by about 7%. In ICF the sodium concentration is much lower due to the Na.K.ATPase pump, and the impermiability
of the bi-lipid cell wall. It is in the range of 10-20mmol/L depending on specific cell. The total distribution of sodium in the body is ECF = 50%, ICF = 5% and bone
45% and the total amount is approximately 60mmol/Kg. Sodium principlally maintains serum osmolality and ECF volume. Sodium plays a crucial role in the
generation of the cell membrane action potential. Disorders of sodium concentration (hyper or hyponatraemia) usually result in from a relative deficit or excess of
water respectively. Serum Na+ concentration and total body Na+ are closely regulated by renal functions. Sodium is easily filtered by the glomeruli of the kidneys,
and most of it reabsorbed by the renal tubules. Several hormones, including aldosterone, ANP, and vasopressin control the reabsorption of sodium and water to
maintain the amount of total body Na+. Aldosterone is responsible for renal Na+ reabsorption in exchange for for K+ and H + in the distal convoluted tubules and
the collecting ducts of the kidneys. Atrial naturetic peptide has an opposing effect by increasing renal excretion of Na+ it tends to decrease plasma volume.
Normally, changes in serum Na+ and osmolality lead to an appropriate change in vasopressin release by the posterior pituitary which in turn can vary renal free
water excretion (urine osmolality 50-1400) in order to maintain Na+ in the normal range. Daily intake of sodium is approximately 10.5g (457mmol) since (at rest)
11 mmol is lost in faeces and 11 in sweat (nb this is highly variable) the kidneys must excrete the remaining 435 mmol (10g). The end result of these physiological
processes is that in situations where there is Na+ loss, for example diarrhoea or excessive sweating, renal Na+ conservation is high and urinary Na+ concentration
falls to very low levels. However when Na+ intake is excessive, decreased tubular reabsorption leads to the loss of increased sodium in the urine.
Potassium is the major intracellular cation and normally has an ICF concentration of 150mmol/L which is about 30 times that of the ECF (normal range 3.5-5). The
total amount of potassium in the body is about 40-45 mmol/kg. The distribution of K+ in the body is ICF = 90%, ECF = 2% and Bone = 8%. It is often said that
potassium is 98% ICF and 2% ECF, and whilst this is factually incorrect it is useful from a clinical perspective because the bound potassium in the bone is not
physiologically mobile therefore often ignored. Serum potassium is a function of two variables, the total body potassium and the distribution between ICF and ECF.
There are numerous major functions of potassium in the body including cell volume regulation (as the major intracellular tonicity component and its role in the
Na.K.ATPase pump), intracellular pH regulation, DNA and protien synthesis, growth, enzyme functions, resting membrane potential, cardiac and neuromuscular
activity. Total body K+ and serum K+ are closely regulated by the renal tubules, so that potassium excretion is usually equal to daily potassium intake (1.5-5g per
day). There are several hormones, including aldosterone, adrenaline and insulin that effects on K+ concentration. Aldosterone facilitates sodium reabsorption in
exchange of K+, resulting in increased renal secretion of K+ . Adrenaline and insulin alter K+ by shifting it back into cells. Plasma K+ is also influenced by the
acid-base status this is because in acidaemia H+ are preferentially excreted instead of K+ leading to hyperkalaemia and visa versa. The most serious manifestations
of hyperkalemia are muscle weakness or paralysis, cardiac conduction abnormalities, and cardiac arrhythmias this is caused by alterations in the generation of
action potential. These manifestations usually occur when the serum potassium concentration is 7.0 meq/L with chronic hyperkalemia or possibly at lower levels
with an acute rise in serum potassium. ECG changes include (progressively) peaked T wave, shortening of the QT interval, prolonged PR interval, p-wave flattening,
widening of the QRS and finally a sine wave appearance, VF or asystole. Hyperkalemia also interferes with renal ammonium (NH4+) excretion, thereby limiting acid
excretion and possibly leading to the development of metabolic acidosis. The pattern of weakness in hypokalemia is similar to that associated with hyperkalemia.
In addition to causing muscle weakness, severe potassium depletion (serum potassium less than 2.5 meq/L) can lead to muscle cramps, rhabdomyolysis, and
myoglobinuria. A variety of arrhythmias may be seen in patients with hypokalemia. These include premature atrial and ventricular beats, sinus bradycardia,
paroxysmal atrial or junctional tachycardia, atrioventricular block, and ventricular tachycardia or fibrillation. Hypokalemia produces characteristic changes on the
ECG although they are not seen in all patients. There is depression of the ST segment, decrease in the amplitude of the T wave, and an increase in the amplitude of
U waves which occur at the end of the T wave. Hypokalaemia may also lead to renal abnormalites and gluclose intolerance (through the decreased excretion of
insulin).
Calcium is found predominantly in the bone (99%) and the ICF (1%). Serum calcium is approximately 40% protien bound (mostly albumin), 10% chelated to serum

anions and 50% in free ionised form. It is the latter which has an ECF concentration of 1-1.5 mmol/L which is the physiological active component. Ionised calcium (Ca2+ )
in the ICF is at a concetration of approximately 50 mmol/L. Ca2+ performs many important functions including neuromuscular transmission, excitation-contraction
coupling in muscles, release of hormones and neurotransmitters, enzyme activation, blood coagulation, and bone structure. It is also an important intreacelllular second
messenger. Calcium is regulated by two primary hormones, parathyroid hormone (PTH) and 1,25 dihyroxy-vitamin D (activated vitamin D). Both of these are secreted in
response to a decrease in serum ionised Ca2+, and stimulate Ca2+ release from bone, reabsorption from the renal tubules and absorption from the intestines. They are
able to maintain a tight calcium control even in the setting of decreased intake. Patients with mild hypercalcemia (calcium [3 mmol/L]) may be asymptomatic, or they
may report nonspecific symptoms, such as constipation, fatigue, and depression. A serum calcium of (3 to 3.5 mmol/L) may be well-tolerated chronically, while an acute
rise to these concentrations may cause marked symptoms, including polyuria, polydipsia, dehydration, anorexia, nausea, muscle weakness, and changes in sensorium.
As calcium is an inotrope the cardiovascular symptoms/signs are shortening of the QT interval, bradycardia, hypertension. Hypocalcemia may be associated with a
spectrum of clinical manifestations), ranging from few if any symptoms if the hypocalcemia is mild, to life-threatening seizures, refractory heart failure or tetany (initally
perioral tingling, then sensorium changes and cramps progressing to laryngospasm) if it is severe. In addition to severity, the rate of development of hypocalcemia and
chronicity determine the clinical manifestations.

Magnesium is the fourth most common cation in the body and is found mostly in the ICF and in the bone. Of total body Mg2+ , 99% is intracellular and only 1% is

extracellular. Of the normal serum, Mg2+ (normal range 0.8-1.2mmol/L) free ionised Mg2+ represents approximately 50% this amount and is the physiologically active
component. Serum Mg2+ is regulated by renal excretion. Free Mg2+ is an essential co-factor for ATP requiring enzymes such as the cell membrane Na.K.ATPase pump and
more than 300 enzymes involved in energy metabolism. Mode of action: Many processes are dependent on magnesium (Mg2+) including the production and functioning
of ATP (to which it is chelated) and the biosynthesis of DNA and RNA. It has an essential role in the regulation of most cellular functions. It acts as a natural calcium (Ca2+)
antagonist. High extracellular Mg2+ leads to an increase in intracellular Mg2+, which in turn inhibits Ca2+ influx through Ca2+ channels. It is this non-competitive inhibition
that appears to mediate many of its effects. It also competes with calcium for binding sites on sarcoplasmic reticulum thereby inhibiting its release. High concentrations
inhibit both the pre-synaptic release of ACh and as well as post-junctional potentials. Mg2+ also has an antiadrenergic action: release at all synaptic junctions is decreased,
and it inhibits the release of catecholamines. Central and peripheral nervous systems : Magnesium penetrates the bloodbrain barrier poorly, but it nevertheless
depresses the CNS and is sedating. It acts as a cerebral vasodilator, and it interferes with the release of neurotransmitters at all synaptic junctions. Cardiovascular: It
mediates a reduction of vascular tone via direct vasodilatation. It also causes sympathetic block and the inhibition of catecholamine release. Magnesium decreases
cardiac conduction and diminishes myocardial contractile force. This intrinsic slowing is opposed partly by vagolytic action. Respiratory: Magnesium has no effect on
respiratory drive, but it may weaken respiratory muscles. It has some bronchodilatory effects hence its use in asthma. Uterus It is a powerful tocolytic, which has
implications for mothers who are being treated with the drug to control hypertensive disease of pregnancy prior to delivery. Normal adult requirements are 0.4
mmol/L/kg/day orally or a quarter this parentally. Magnesium replacement has been shown to reduce arrythmias in post MI patients even when initially magnesium
replete although the mechanism for this is not clear. It is also used in pre-eclampsia and acute severe asthma. Hypomagnesaemia is common in critically ill patients and
many drugs, including catecholamines, aminoglycosides and diuretics will lower this further. The symptoms of low magnesium are variable, the most concerning is the
increased risk of arrhythmias. Hypermagnesaemia is more clearly defined. Initial symptoms include nausea, vomitting and drowsiness. ECG changes occur from the range
of 2.5-5, and are characterised by increased PQ and widened QRS. At roughly 5.0 loss of the patellar reflex In the range of 6-8 there is a respiratory paralysis, 7.5 complete
heart block and finally at greater than 12 asystole.

Phosphate is found mostly inside the cell. Bone accounts for 85%. The normal serum phosphate level ranges from 0.8 to 1.3 mmol./L in adults. Serum phosphate is

regulated by renal excretion. It follows that the most common cause of hyperphosphotaemia is renal failure (others include tumour lysis syndrome, rhabdomyolysis
and lactic acid ketoacidosis). Phosphate plays a vital role in oxidative phosphorylation of carbohydrate, fat and protein metabolism. Phosphate is a structural
component of nucleic acids, phopholipids and the cell membrane. It is also essential for intracellular second messenger systems including cAMP and IP3. As part of 2,3
DPG it assists in the offloading of oxygen from Hb to tissue. Hyperphosphotaemia is symptomatic when the increased binding of calcium leads to hypocalcaemia
(seizures, heart failure and eventually tetany). Hypophosphotaemia is common in intensive care patients and may cause muscle weakness. It is often used as a marker
of refeeding syndrome.

Christopher Andersen 2012

DIURETICS
Diuretics are drugs that increase the rate of urine flow; clinically useful diuretics also increase the rate of excretion of Na+ (natriuresis) and an accompanying anion,

usually Cl. Most clinical applications of diuretics aim to reduce extracellular fluid volume by decreasing total-body NaCl content. As previously described the osmolality is
the most important determinant of total body water. Although continued administration of a diuretic causes a sustained net deficit in total-body Na+, the
time course of natriuresis is finite because renal compensatory mechanisms bring Na+ excretion in line with Na+ intake, a phenomenon known as diuretic braking.
Compensatory mechanisms include activation of the sympathetic nervous system, activation of the reninangiotensinaldosterone axis, decreased arterial blood pressure
(which reduces pressure natriuresis), hypertrophy of renal epithelial cells, increased expression of renal epithelial transporters, and perhaps alterations in natriuretic
hormones such as atrial natriuretic peptide. Therefore several days after initiation of a diuretic a new steady state is established with lower overall TBW. Diuretics are
typically classified in two ways. Firstly into two groups based on the principle action, which is either naturesis (loss of sodium) or aquaresis (loss of water directly). The most
common slassification system is based on the site of action in the kidneys and specific mechanisms. This is shown below.

H+

Proximal tubule
2K+
Na+
CO2 + H2O

Proximal tubule

Carbonic anhydrase inhibitors (acetazolamide) reduce Na+ reabsorption by


their
effect
on carbonic anhydrase. This is because up to a third of PT Na+ reabsorption
HCO3occurs in exchange for H (through the Na-H antiporter) and is thus dependent on CA.
carbonic
Even though this represents a large amount of Na , the total diuresis for CA inhibitors
anhydrase
and osmotic agents as well is much lower because there is significant compensation by
the more distal tubules which will reabsorb increased sodium if it is delivered due to
osmosis
H2O / NaCl decreased reabsorption proximally. CA inhibitors are responsible for a 5-10% excretion
Proximal
increase in the filtered load.
Osmotic Agents the most common osmotic agent is mannitol. As the name implies they inhibit the
Tubule
reabsorption of solute and water by altering osmotic driving forces along the nephron. Unlike other classes of
diuretics, osmotic diuretics do not inhibit a specific membrane transport protien. Osmotics like mannitol are freely
filtered at the glomerulus but are poorly reabsorbed. Because the proximal tubule is involved in the reabsorption of
60-70% of the filtered load this is the most important site of action. When there is an osmotic diuresis the blood flow
to the medulla is increased and this reduces the effectiveness of the countercurrent mechanism, as a result less water
in reabsorbed in the thin descending limb of the loop of Henle and the cortical collecting duct.
3Na+

Distal convoluted
tubule

Thick ascending
loop of Henle

Cortical
Collecting
Duct

Thick ascending

Thick ascending loop of Henle

Na
2ClK+
+

2K

3Na

sodium-potassiumchloride symporter

Distal convoluted
3Na+
Na+
Cl-

2K+

Sodium-chloride
symporter

Principle Cell

2K+

3Na+

Na+
ENaC Sodium
Channel

Intercalated Cell

Aquaporins
H2O

Loop Diuretics (Frusemide) are organis ions that enter the tubular lumen primarily through
secretion into the proximal tubule. They inhibit Na+ reabsorption by blocking the Na+.K+.2Cl- symporter
located in the apical membrane of these cells. By this action they not only inhibit Na+ reabsorption but
also interupt the countercurrent mechanism and he bodys ability to dilute or concentrate urine. This
also leads to decreased urine reabsorption in the TAL and the CCD. Loop diuretics are the most potent
diuretics available, and are responsible for an 25% increase in the excretion of sodium filtered load.
This reflect the fact that there is limited opportunities for reabsorption distal to the TAL.

Distal convoluted tubule

Thiazide diuretics (hydrochlorothiazde) are, like the loop diuretics organic anions. They are also mostly bound to plasma
protiens, and they gain access to the tubule via secretion in the proximal tubule. They act to inhibit Na+ reabsorption in the early
portion of the distal tubule by blocking the Na+.Cl- symporter in the apical membrane of these cells. Because water cannot cross this
portion of the nephron, it is a site where urine is diluted. Therefore thiazides reduce the ability to dilute the urine maximally by
inhibiting NaCl reabsorption. Because they act in the cortex they do not effect the ability of the kidneys to concentrate the urine
maximally. Naturesis with thiazide diuretics is 5-10% of the filtered load.

Cortical collecting duct (and late distal tubule)

Potassium sparing diuretics these are divided into two classes, those which antagonise the action of aldosterone
(spironolactone) and those which which block entry of Na+ into the same cells through the Na+ selective channels (ENaC) in the apical
membrane (amiloride). Aldosterone stimulates both Na+ resorption and K+ secretion by the principles cells of the CCD. Thus the presence
of a aldosterone antagonist these effects are reduced. The result of drugs such as amiloride is similar but rather than antagonise
aldosterone they act directly on the ENaC channel. The result of both is decreased reabsorption of Na+ which leads to decreased
extrusion by the Na+.K+.ATPase pump and therefore less intracellular K+, and ultimately less K+ secretion into the tubular fluid.
Aquaretics are a more recent development and involve the direct antagonism of the V2 receptor which responds to ADH and
is responsible for increasing the numbers of intergral membrane proteins called aquaporins. Aquaporins, especially when located in the
CCT, enable the recovery of water by osmotic processes facilitated by the counter current mechanism. These drugs may be especially
helpful in the treatment of patients with serious complications associated with SIADH.

Christopher Andersen 2012