The osmolarity of body fluids relies heavily on the ability of the kidney to produce dilute or concentrated urine. Urine concentration depends on three factors: (1) the ‘osmolarity of interstitial fluids in the urina-concentrating part of the kidney, (2) the antidiuretic hormone (ADH), and (3) the action of ADH on the cells in the collecting tubules of the kidney. Osmolarity. In approximately one fifth of the jaxtamedullary " Ge es ee Deed eRueueIny wend the dey forma entrant systema set of parallel passages in ‘which the contents flow in opposte tirecions. The countercurrent Sere inene te oxmelay In be cece eden peeeoee tae eat Bee GS a mds Da ees ae cleterting and ascending ections of tha ca Teac of thse . cesses high concentra tion of ‘osm aly acne pares {approximately 1200 a FqO collects in the interstsum sur- rounding the collecting tubules where ie ee eoct sage at poe eee ‘Antidluretie Hormone. ADH, which reeulats the ability of the kidneys to concentrate urine, is fheurons in the Hypothalamus. and piper ec es nor an enero ee the main stimuli for symfesis and lee earners ae eet pesca a eee ee sey eee ater _ na re ees sine: crossed ‘tow and concerted‘Action of ADH. ADH, also known {as rasopressin, actsat the level of the collecting tubule to increase water absorption. It exerts its action by the basolateral’ membrane’ of che tubular cell Binding of ADH to the ‘vasopressin receptors causes water channels 1-2 channels) to ‘move into the lumiral side ofthe cll ‘membrane, which normally imper- ‘meable, to’ water. Insertion of the channelsallows watr from the tubu- lar fluids to move ico the tubular call fmeinerl se of he cll rd from there it moves into the peritubular ‘capillaries for returnto the circulatory “Ts, when ADH is presen, eseerereretceri anced and when ADH is absent, is excreted in the ure. Flr Fenctons or tn ney 1m The kidney regulates the compcaition and pH of body fluids through the reabsorption and elimi- ‘nation or conservation of sodium, potassium, hhydrogen, chloride, and bicarbonate ions. 1M It unctions in the elimination of metabolic ‘wastes (urea, ure acid, creatinine) and drugs and ‘their metabolites. It sorves to regulate the osmolality of the oxtra- ‘cellular fluid through the ection of antidiuretic hormone (ADH). It plays a central role in blood pressure regula tion through the renin-angiotonsin-aldosterone ‘mechanism and the regulation of salt and water ‘eurmination. {Wit contributas to the metabolic functions of the ‘skolatal systom through activation of vitamin D and ragulation of caiclum ana pnosphate conser- ‘vation and alimination, Mt controls the production of red blood calls in ‘the bone marrow through the production ot ‘erythropoietin.Calor: yellow-amber—indicates a high specific Glucose: negative Casts negative: occasional hyaline casts, gravity and small output of urine Ketones: negative Red blood cells: negative or rare “Turbidity: clear to slightly hazy Blood: negative Crystals: negative (none) Specific oravity: 1.010-1.025 with a normal Protein: negative White blood cells; negative or rare uid inate Bilirubin: negative Epithelial cells: few pH: 45-80 Urobilinogan:0.5-8.0 mgd [Nitrate for bactaria: negative Leukocyte esterase: negative “The function of the kidneys isto filter the blood, selec- ively reabsorb those substances Uatare need to uit tain the constancy of body fd, and excrete metabolic 7 ‘wastes, The composition of urine and blood provides [Tests of Renal Function tion. Radiologie tests, eadoscopys and renal biopsy ‘afford means for viewing the gross and microscopic ‘Sructurs of the kidneys and urinary spstem, Blood Tests Blood tests can provide valuable information about the kidneys" ability to remove metabolic wastes from the Socduiee iran 8008 28-74 mot yy co remorg abel, wae sos Sgeeet Segoe el aplnaygomalsowabeg arth omy Sodium 135-145 mEq/L (135-145 mmol/L) ‘Table 24-2. Serum levels of potassium, phosphate, Chloride 98-106 mEq/L (98-106 mmol/L) BUN, and creatinine increase in renal failure. Serum Potassium 3.5.5 mEq/l (3.5-5 mmol/L) [, calcium, and bicarbonate levels decrease in renal_ SeTows Seen Ssrmmll paste ad et le dea al “condos fee Testo oul ug ore cones es ssinsmetetzemmety anne” See SUS nome se 2. ¢mg ab- pmotts ee PELEM eseeat pH 735-745. “Values may vary among laboratorias, depending on the method of ‘analysis used.Glomerular Filtration Rate and Other Indicators of Renal Function “The GFR is considered the bet measure of overall func- tion of the kidney. The normal GFR, which varies with age, sex, and body size, is approximately 120 to 130-ml/ minutll-73 m for normal young healthy adults." A GER below 60 mL/minutel1.73 my represents a loss of one half or more of the level of normal adult kidney function." In clinical practice, GFR is usually estimated using the serum creatinine concentration. Creatinine, a -product of muscle metabolism, is freely filtered in the glomerulus and is not reabsorbed in the renal tubules. It is produced at a relatively constant rate by ‘muscles in the body, and essentially all the creatinine that is filtered in the glomerulus is lost in the urine rather than being reabsorbed into the blood, Thus, serum creatinine can be used as an indirect method for Assessing the GIR and the extent of kidney damage that has occurred in CKD. ‘Although the GFR can be obtained from measurements of creatinine clearance using timed (eg 24-hour) urine ‘collection methods, the levels gathered are reportedly no more reliable than the estimated levels obtained by using serum creatinine levels" Because GFR varies with age, sex, ethnicity, and body size, the Modification of Diet in Renal Diseases (MDRD) equation that takes these factors into account is often used for the GER based on serum creatinine levels" (available online at http! ‘wivw-kidney.orp/professional/k dogifgfci)- Proteinuria serves as key adjunctive tool for mea- suring nephron injury and repair Urine normally con- tains small amounts of protein. However, a persistent increase in protein excretion usualy isa sign of ki damage. The type of protein (e-s., ioecmacna wet tlobulins or albumin} depends om the type of kidney fase. Increased excretion of low-molecular-weight slobulins isa marker of tubulointersttial disease, and fexcretion of albumin is a marker of CKD, resulting from hypertension or diabetes mellitus, For the diagnosis of CKD in adults and postpuberal children with diabetes, measurement of urinary albumin is preferred." In most ‘Cases, urine dipstick tests are acceptable for detecting alburninutia Ifthe urine dipstick test is positive (1+ of {reater), albuminuria is usually confirmed by quantita- five measurement of the albumtn-to-creatinine ratio ina Spot (untimed) urine specimen." Microalbuminuria, Which isan early sign of diabetic kidney disease, refers toalbumin excretion thats above the normal range but below the range normally detected by tests of total pro- tein excretion inthe urine. Populations at risk for CKD {ie., those with diabetes mellitus, hypertension, or fam- ily history of kidney disease) should be screened for microalbuminuria, at least annually, as part of their health examination." ‘Other markers of kidney disease include abnormalities in urine sediment (red and white blood cells) and abnor- ‘mal findings on imaging studies."*""" Ultrasonography is particularly useful for detecting a number of kidney dis- orders, including urinary tract obstructions, infections, stones, and; kidney disease. Other fests such as red blood cell indices, serum albumin levels, plasma elec- trolytes, and blood urea nitrogen are used to follow the progress of the disorder. 1.A 32-year-old woman with diabetes is found to hhave a positive result on a urine dipstick test for ‘microalbuminuria. A subsequent 24-hour urine specimen reveals an albumin excretion of 50 mg (an albumin excretion >30 mg/day is abnormal). ‘A. Use the structures of the glomerulus in Figure 24-5 to provide a possible explanation for this finding. Why spectically test for the albumin rather than the globulins or other plasma pro- teins? and treatment of hypertension have been shown to decrease the ression of kiciney disease in persons with Eizbetes. Explain the physiologic rationale for these two types of treatments. 2.A 10-year-old boy with bed-wetting was placed ‘on an ADH nasal spray at bedtime as a means of ‘treating the disorder. ‘A. Explain the rationale for using ADH to treat bed-wetting. 3. A S4-yearold man, seen by his physician for an peel al eee cere serum creatinine of 2.5. He complains that he has been urinating more frequently than usual and his first morning urine specimen reveals a dilute urine with a specific gravity of 1.010. ‘A. Explain the elevation of serum creatinine in gpl he nail of persons with eal rezal B. Explain the inabili ith early rena ee ee cdenced by the frequency of urination and the low specific gravity of his ist morning urine specimen.Gomeruiar ‘basement © momorane FIGURE 2-5. Renal corpuscle. (A) Structures ofthe glomeru- us. (B) Cross-section ofthe glomerular membrane, showing the position ofthe endotholium, basement membrane, and epitalial foot processes. (€) Position ofthe mesangial c ‘elation tothe capillary loops and Bowman capsule, pita foot processes Endothetum “Thick ascanaing loop of Henle cat ‘easotatoral ‘cal memorane ‘uminal cell memorane FIGURE 24-10. Sodium, chloride, and potassium reabsorption inthe thick segment ofthe loop of Henle ‘pasolatoral ‘call memorane FIGURE 24-11. Mechanism of sodium reabsorption and [potassium secration by principal calls ofthe late distal and the activity ofthe Na'/K'-ATPase pump that transports sodium ‘outward through the basolateral membrane ofthe cell and into the blood atthe same time # pumps potseaium inte the cal, [Aldos.erone also increases the permeability ofthe luminal ‘mombrane for potassium.