KIDNEY, BODY FLUIDS, AND ACID-BASE BALANCE

- DR. VIVEK NALGIRKAR

THE KIDNEYS:

Kidneys perform a number of functions that are crucial for homeostasis ~

Regulation of body fluid volume and osmolality, regulation of electrolyte
composition, excretion of metabolic waste products, excretion of other foreign
chemicals (e.g. drugs), gluconeogenesis, synthesis of erythropoietin, vitamin D,
and renin.

 Structure and circulation –

- The basic functional unit is a Nephron. {About 1 million nephrons in
each kidney.}
- A nephron consists of a filtering component called the renal corpuscle
and a system of tubules that extends from the renal corpuscle. The renal
corpuscle has a vascular pole – the glomerulus (a tuft of capillaries), and
a renal (or urinary) pole – the Bowman’s capsule. As blood enters the
glomerulus via afferent arteriole, about 20% of the plasma filters into
the Bowman’s capsule. The remaining blood leaves the glomerulus via
the efferent arteriole.
- The afferent arteriole is short and wide; the efferent arteriole is narrow
and long. Hence, glomerular capillary pressure is much higher, which
favors filtration.
- All components of plasma, except proteins, are filtered into the
Bowman’s capsule.
- The filtrate then flows through the tubules – the first part is proximal
convoluted tubule (PCT) and proximal straight tubule. Then, the U-
shaped loop of Henle, which leads to distal convoluted tubule (DCT), and
finally the collecting tubules drain into the collecting duct. The various
segments of tubules reabsorb the filtered components of plasma that
 are needed to be retained in the body. Some substances are secreted
from the blood into the tubular fluid, to be excreted into the urine. Final
composition of urine is decided at the collecting duct.
- Let us consider an analogy. If we have to clean and set up a cupboard,
what would be the steps? (1) We will first remove all the contents
present in the cupboard. (2) The articles that we want to retain will be
again arranged back; some new contents may also be added. (3)
Unwanted contents will be discarded.
Steps in the urine formation are somewhat similar:
1. Glomerular filtration – Except for proteins, all the contents are
removed from plasma by glomerular filtration.
2. Tubular reabsorption – As the filtrate starts flowing down into the
tubules, the substances required by the body are absorbed back into
blood.
3. Tubular secretion – Some substances that are to be eliminated out of
the body are secreted from blood into the tubular fluids. Substances
not reabsorbed and the substances secreted will be finally excreted
in urine.
Final urine formation = (glomerular filtration + tubular secretion) –
tubular reabsorption.
- The glomerular filtration barrier: It prevents the passage of cells and
high-molecular-weight proteins into the glomerular ultrafiltrate so that
they are not lost into the urine. The barrier is made up of ~ (i)
Endothelial cells of the glomerular capillaries, (ii) The basement
membrane of these capillaries, and (iii) Foot processes of the podocytes.
{Podocytes are epithelial cells that overlie the basement membrane.}
[Figure: components of the glomerular filtration barrier.]

- “Columns of Bertin”: projections of the renal cortex; they form the

lateral boundaries of renal pyramids.
- “Duct of Bellini”: Several collecting tubules, from different nephrons,
join to form the duct of Bellini, which opens at the apex of the renal
pyramid.
- A kidney has two regions: An outer cortex and an inner medulla. 85%
nephrons are cortical (entire nephron in the cortex, short loops); 15%
are juxtamedullary (glomeruli at the junction of cortex and medulla, long
loops). Cortical nephrons are fully functioning under normal conditions;
juxtamedullary nephrons work in conditions of stress.
[Figure: Components of a nephron. The juxtamedullary nephron (on the left) has a glomerulus
at the border of the renal cortex and medulla; and a long loop that goes deep into the inner
medulla. The cortical nephron (on the right) has a glomerulus superficial in the cortex and a
short loop of Henle. Reference: Medical Physiology by Rhoades & Bell, 3rd edi., pg. 393.]

 Juxtaglomerular apparatus (or JG apparatus): (short note)

- It is a component of tubuloglomerular feedback mechanism that is
involved in the autoregulation of renal blood flow (RBF) and the
glomerular filtration rate (GFR) (discussed later).
- In each nephron, the thick ascending limb of loop of Henle touches the
vascular pole of the glomerulus; at this site is the JG apparatus. It
consists of the following structures -
 The granular juxtaglomerular cells in the afferent arteriole. They
are modified smooth muscle cells (of the vessel). These cells
synthesize and secrete renin.
 The macula densa at the end of the thick ascending limb and the
initial portion of DCT. It consists of densely crowded epithelial
cells of the tubule. These cells monitor the composition of the
fluid in renal tubules at this point.
 The extraglomerular mesangial cells. [or ‘Lacis cells’] They may
transmit information from macula densa cells to the granular
cells.
 Functional significance of JG apparatus:
1. Tubuloglomerular feedback mechanism: [Tubule →
glomerulus; negative feedback]
 It is a negative feedback system that stabilizes renal
blood flow and GFR.
 Increased renal Increased GFR
blood flow

Increases NaCl delivery

to macula densa

Increased NaCl reabsorption

and increased ATP
breakdown

ATP → ADP → AMP → adenosine

Renal blood flow

decreases
Adenosine reaches Constriction of
afferent arteriole afferent arteriole
GFR decreases

[Two important points should be noted here -

A. Na+ reabsorption from renal tubules involves active transport process, and
it is energy-dependent. In fact, ATP breakdown by kidneys is directly
proportional to the amount of Na+ load presented to the tubules.
B. Adenosine is a vasodilator elsewhere in the body. However, in kidneys, it
causes vasoconstriction (by acting via different types of receptors).]

2. Regulation of blood volume and blood pressure:

  The granular or JG cells are sensitive to stretch; they
function as intra-renal baroreceptors. A decrease in
pressure in the afferent arteriole can be sensed by the
granular cells.

Decrease in blood volume and

blood pressure (e.g. due to
hemorrhage, diarrhea, etc)

Sensed by
the granular
(JG cells) of
the JG
apparatus
JG cells secrete
RENIN

Blood

ANGIOTENSINOGEN Angiotensin I

ACE
(lungs)

Angiotensin II

Secretion of
aldosterone by
adrenal cortex

Blood volume
increases; blood
Aldosterone acts Na+ and water pressure
on renal tubules reabsorption increases
~ Peculiarities of renal circulation:

o Kidneys receive about 22% of the cardiac output; a very high fraction
considering that kidneys weigh only about 1-2% of the body weight. In
terms of blood flow per 100 gm of tissue, the renal blood flow (RBF) is 4
times greater compared to blood flow to liver or exercising muscle and 8
times the coronary blood flow.
o Capillary hydrostatic pressure, compared to elsewhere, is highest in
kidneys.
o Capillary filtration coefficient is highest in kidneys: 12.5 ml/min./mm Hg
o A-V O2 difference is least in kidneys (1.7 ml of O2/100 ml of blood;
elsewhere it is 5 ml/100 ml of blood)
o In kidneys: Metabolic rate is proportional to the blood flow. Increased
blood flow in glomerulus → more Na+ filtered → more Na+ load to the
tubules. O2 consumption is directly proportional to Na+ reabsorption by
tubules (role of Na+-K+ ATPase). (Elsewhere; rate of blood flow is
proportional to metabolism.)

~ Blood flow is greater in the renal cortex since all the glomeruli are located in the
cortex. Oxygen extraction is more in the renal medulla since O2 consumption is
directly proportional to the Na+ load to the tubules; Na+ load is greater in the
medullary tubules of juxtamedullary nephrons.

 Methods in renal physiology:

1. “Clearance” measurements –
“Clearance” is a measure of the volume of plasma completely cleared of
a given substance per unit time by the kidneys.
It is the ratio of renal excretion rate of the substance to its
concentration in the plasma.
 For a substance “x” – Total plasma concentration is Px.
Its urinary concentration is Ux, and total volume of urine is V.
Then, its total excretion will be Ux × V. {E.g. if urinary concentration is 2
mg/mL, and urine volume is 100 mL/min., then total excretion of the
substance in urine would be 2 × 100 = 200 mL/min.}
Clearance rate of the substance would be:

Cx = (Ux × V)

Px
{It means, total amount of “x” in plasma is Px, and out of it, (Ux × V) is excreted in
urine per unit time.}

~ Inulin clearance is used to measure GFR: (Cinulin = GFR)

- Inulin is a fructopolysaccharide.

- When injected, it does not bind to plasma proteins.

- It is freely filtered at the glomerulus.

- It is neither secreted nor reabsorbed by the tubules.

Inulin is freely filtered at glomerulus. Then, it is neither reabsorbed nor secreted

by the tubules. It means, all the filtered amount is excreted in urine. All the
urinary inulin is coming as filtered amount. Thus, from its urine level, its rate of
filtration can be assessed. And, its rate of filtration is almost same as “glomerular
filtration rate” (GFR) (since it is freely filtered at glomerulus, just like plasma).
Hence, inulin is used to measure GFR.

Other substances that can be used: mannitol, iothalamate.

However, all these have to be injected I.V.

In clinical setting, endogenous creatinine clearance is used to measure GFR, most

commonly.
Creatinine is formed from muscle creatine; it is excreted in urine as a waste
product.

Mass of creatinine excreted per unit time ≈ mass of creatinine filtered per unit
time

Ucr × V ≈ Pcr × GFR

Thus, GFR would be equal to: (Ucr × V)

Pcr

{There are two related issues. (i) Urinary concentration of creatinine (U cr) is an
overestimation of GFR. Reason: Some 10 to 15% of creatinine is also secreted by
tubules. Thus, urinary concentration of creatinine is NOT only the filtered
creatinine. (ii) Plasma concentration of creatinine (Pcr) is an underestimation of
GFR. Reason: Standard colorimetric methods for determining plasma creatinine
measure other chromogens (acetone, proteins, ascorbic acid, pyruvate) in plasma,
in addition to creatinine (“Jaffe reaction”). A falsely high value of Pcr means
underestimation of GFR. The two error components cancel out so that creatinine
clearance is considered to be an approximation of GFR.}

~ Measurement of renal plasma flow (RPF):

The substance used is para-amino hippuric acid [PAH].

To determine blood flow to kidneys, Fick’s equation can be used.

Fick’s equation is used for determination of cardiac output for the entire body, or
for determination of blood flow to an organ.
Fick’s equation:

Cardiac output or blood flow = O2 consumption ÷ (arterio-venous O2 difference)

Instead of O2, using a substance “x” for measuring blood flow to kndneys:

Renal plasma flow = consumption of “x” by kidneys

RAx - RVx

{RAx and RVx are concentrations of “x” in renal artery and renal vein, respectively.
And, (RAx – RVx) is arterio-venous difference in the level of “x”.}

 The numerator: Consumption of “x” by kidneys. The substance “x” should

be “consumed” by kidneys, NOT by metabolism, but by excretion into
urine. In that case, “consumption” of “x” will be same as its urinary
excretion (that is, Ux × V). {The numerator in the equation}
 Now, for the denominator: If the substance is not “consumed”
(metabolized etc) by any tissue other than kidney, then renal artery
concentration of “x” (RAx) will be same as systemic plasma concentration of
it (that is, RAx = Px).
 And, if the substance is totally removed by kidneys in a single pass, its
venous concentration (RVx) will be zero. Thus, the denominator will be (Px –
0 =) Px.
 The entire equation now becomes the clearance equation for “x”:

RPF = Ux × V
Px
 All the above mentioned characteristics are shown by PAH. Hence, it is the
ideal substance to measure RPF.
 Renal blood flow is then calculated by the equation:

RBF = RPF/(1 – hematocrit)

(Between plasma and blood, difference is that of hematocrit. Hence, from the
plasma flow, blood flow can be calculated by the above equation.)
~ Glomerular filtration rate: [LAQ: factors determining or influencing GFR]

{Starling’s forces acting at the glomerulus}

Glomerular filtration rate (GFR) is the amount of filtrate formed by the two
kidneys per unit time.

 Normal GFR = 125 mL/min. or 180 L/day.

 Note that: 180 L of filtrate is formed every day. But the final urine volume
per day is only about 1 to 1.5 L. It means, almost 178 L of the filtered
volume is reabsorbed by the tubules.

~ Glomerulus is a tuft of capillaries. As blood enters these capillaries, plasma

along with its solutes are filtered into the Bowman’s space first.

Filtration of substances across a capillary membrane is governed by the so-called

“STARLING’S FORCES” acting in and around the capillaries.
 Plasma
colloid Capillary
osmotic hydrostatic
pressure pressure

Interstitial Interstitial STARLING’S FORCES:

fluid fluid colloid Hydrostatic pressure
hydrostatic osmotic Colloid pressure
pressure pressure

~ Starling’s forces that cause movement of fluid into or out of a capillary:

Basically, there are two forces or pressures that are responsible for fluid
movement: (1) Hydrostatic pressure, (2) Colloid osmotic pressure.

(1) Hydrostatic pressure:

- It is a force that pushes fluid or water away from it into the neighboring
compartment.

- It is exerted by the accumulated fluid or water (“hydro”, “static”). It is

proportional to the amount of the accumulated fluid; greater the
accumulated fluid, greater will the hydrostatic pressure.

a. Capillary hydrostatic pressure – It is exerted by the blood (plasma)

within a capillary. It forces the plasma fluid out of the capillary.
 b. Interstitial fluid hydrostatic pressure – It is exerted by the interstitial
fluid present within a tissue. It tends to push the fluid into the
capillary.

(2) Colloid osmotic pressure:

- It is a force exerted by the proteins in a compartment.

- It tends to pull fluid or water into the compartment by osmosis.

a. Plasma colloid osmotic pressure – It is exerted by the plasma

proteins in the vascular compartment. It pulls water into the capillary
by osmosis.

b. Interstitial fluid colloid osmotic pressure – It is exerted by the

proteins in the interstitial fluid. It tends to pull water out of the
capillary into the interstitium.

With the understanding of these forces, we can now discuss the factors that
determine the GFR. Instead of interstitial fluid, we will have fluid in the Bowman’s
capsule here.

1. Factors favoring filtration at the glomerular capillaries:

Glomerular CAPILLARY HYDROSTATIC PRESSURE. It tends to push the

plasma fluid out of the glomerular capillaries, into the Bowman’s capsule.

This pressure is about 60 mm Hg.

2. Factors opposing filtration at the glomerular capillaries:

a. Plasma colloid osmotic pressure: It is exerted by the plasma proteins (of

the glomerular capillaries). It tends to pull the fluid back into the
capillaries; thus it works in the opposite direction (that is, against
filtration). It is about 32 mm Hg.
 b. Bowman’s capsule hydrostatic pressure: It is exerted by the filtrate
accumulated in the Bowman’s capsule. It tends to push the fluid back
into the glomerular capillaries, thus opposing filtration. It is about 18
mm Hg.

[Note: There is no ‘colloid osmotic pressure of Bowman’s capsule’. Reason:

Proteins do not get filtered from the glomerular capillaries; thus no proteins in
the Bowman’s capsule to exert this pressure.]

 Pressure favoring filtration = 60 mm Hg;

Pressure opposing filtration = (32 + 18 =) 50 mm Hg.

Thus, net filtration pressure = +10 mm Hg. Filtration force will be exerted
by this net pressure.

 For the glomerular capillaries: there is proportionality constant for

filtration, called “capillary filtration coefficient”.

Capillary filtration coefficient = 12.5 mL/min./mm Hg. [For every 1 mm Hg

filtration pressure, the capillaries filter out 12.5 mL of fluid per minute.]

The total “net” filtration pressure is 10 mm Hg. Thus, capillaries will filter
12.5 × 10 = 125 mL/min. Normal GFR = 125 mL/min.

o Filtration fraction:
- Renal blood flow ≈ 1200-1250 mL/min.
- Renal plasma flow would be about 625 mL/min. (plasma is 55% of any
blood volume.)
- Out of this 625 mL of plasma, 125 mL filtrate is formed every minute.
Hence, filtration fraction = 125/625 = 20% or 0.2

~ Factors influencing GFR – {the factors that modify the hydrostatic factor or
colloid osmotic pressure will influence GFR.}

1. High protein diet increases renal plasma flow and GFR.

2. Blood flow into the glomerulus is an important influencing factor.

 - Afferent arteriole brings blood into the glomerular capillaries. Dilatation
of the afferent arteriole will increase blood flow into the glomerulus.
Greater blood flow in the glomerular capillaries → increases hydrostatic
pressure in glomerular capillaries (favors filtration) → This will increase
the GFR.

- Vasodilators: Nitric oxide [NO], PGs, etc – increase blood flow → ↑ GFR

3. Constriction of the efferent arteriole:

- Efferent arteriole takes blood out of the glomerulus. Constriction

(narrowing) of the efferent arteriole → decrease the blood flow out of
the glomerular capillaries → increased blood (accumulated) within the
glomerular capillaries → increased capillary hydrostatic pressure in the
glomerulus → increased GFR.

However, severe constriction of efferent arteriole decreases GFR. As blood

flow out of the glomerulus severely restricted → proteins accumulate in the
glomerulus within glomerular capillaries → colloid osmotic pressure will
increase in glomerulus, opposing filtration → ↓ GFR.
4. Any factor that increases hydrostatic pressure in Bowman’s capsule will
decrease the GFR.
- Obstruction to the tubular flow → fluid will accumulate in the Bowman’s
capsule → ↑ hydrostatic pressure in the Bowman’s capsule → opposes
filtration, GFR decreases.
E.g. obstruction anywhere along the urinary tract because of stones,
ureteric obstruction, or prostate enlargement.
5. GFR decreases with advancing age. With increasing age → loss of
functioning nephrons → ↓ GFR.
6. GFR decreases due to a fall of blood pressure below 60 mm Hg, as in
circulatory shock.
7. It also decreases with erect posture, emotions, pain, exercise, cold stress,
etc.
-------------------------------------------------------------------------------------------------------------
~ Tubular function – (Reabsorption and secretion)
- Once the filtered load starts flowing down the tubules, all the
substances required by the body are absorbed back into blood from
various portions of the renal tubules.
- Some substances from blood, to be eliminated out of the body, are
secreted into the tubular fluid.

~ Whether a substance is reabsorbed or secreted, and how much of it is

reabsorbed or secreted, can be found out by the data:

Px = Plasma level of the substance “x”

GFR = Glomerular filtration rate

Ux = Urinary concentration of “x”; V = Total volume of urine

(Px × GFR) = Total filtration of the substance at the glomerulus --------[A]

(Ux × V) = Total excretion of the substance in urine ----------------------[B]

If [A] > [B], filtered load of the substance is greater than the final excretion of the
substance. It means, the remaining amount was REABSORBED. {E.g. if 100 mg was
filtered and 80 mg appears in urine, the remaining 20 mg was reabsorbed.}

If [B] > [A], amount of the substance excreted in urine is greater than the amount
that was filtered at glomerulus. It means, additionally some substance was
secreted into the tubules. {E.g. 100 mg appears in urine and out of it 80 mg came
from glomerular filtration, additional 20 came from TUBULAR SECRETION.}

~ Sodium reabsorption along the nephron:

  Na+ absorption occurs via transcellular as well as paracellular pathway.
Paracellular transport of Na+ is driven by the transepithelial electrochemical
gradient for Na+.
 For the transcellular pathway:

Tubule
lumen Na+

Na+

Blood vessel

Apical
membrane Na+-K+ pump

Na+ channel

Basolateral membrane

 Na+ reabsorption from tubules occurs as a two step process.

The epithelial cell lining the tubule has two sides: 1. Basolateral membrane
facing the blood vessel, and 2. Apical membrane facing the lumen of the
tubule.
- In the basolateral membrane, there is Na+-K+-pump. It is an active
transporter. It causes Na+ from the cell to move out into the blood
vessel. This decreases the Na+ concentration inside the cell. Na+ from the
tubular fluid can now move into the cell, down its concentration
gradient (high-to-low concentration).
 - In the apical membrane, there is a Na+ diffusion channel. Through this
channel, Na+ from the tubular fluid will move into the lining cell, down
the concentration gradient.
o The Na+ transport through the apical membrane is of different types at
different places along the nephron.
- In the distal part of the nephron (DCT, CD): The apical membrane has
Epithelial Na+ Channel [ENaC]. Na+ from the tubular fluid diffuses
through this ENaC to enter the epithelial lining cell. (Then, Na+ is
removed from the cell, into the blood, by the Na+-K+ pump located at the
basolateral membrane.)
- In the loop of Henle: In the thick ascending part of the loop of Henle,
there is a secondary active transporter – Na+-K+-Cl- cotransporter
[NKCC]. It transports Na+ from the tubular fluid into the cell. It transports
1 Na+: 1 K+: 2 Cl- ions (that is, co-transport of K+ & Cl- along with Na+).
- In the early distal tubule: There is a secondary active transporter called
Na+-Cl- cotransporter [NCC]. It causes co-transport of Cl- along with Na+,
from the tubular fluid into the cell, in ratio of 1 Na+: 1 Cl-.

Segment Fraction of filtered Na+ entry across Regulatory

sodium the apical hormones
reabsorbed membrane
Proximal tubule 67% Na+-H+ exchanger Angiotensin II,
(NHE-3), Na+- Epinephrine, NE,
cotransport with dopamine
amino acids and
organic solutes
Loop of Henle 25% NKCC transporter Aldosterone
(1Na+-1K+-2Cl-
symport)
Distal tubule ~ 4% NCC transporter Aldosterone
(1Na+-1Cl-
symport)
Late distal tubule ~ 3% ENaCs (Epithelial Aldosterone, ANP,
and collecting sodium channels) urodilantin
duct
{NE = Norepinephrine; ANP = atrial natriuretic peptide}

~ Water reabsorption along the nephron: [short note]

o Water reabsorption from various segments of a nephron follows the Na +

reabsorption pattern.

o 67% in proximal tubule, 10-15% in the loop of Henle, and remaining (8 to

18%) in the collecting duct.
o Water absorption from the PCT:
- As the glomerular filtrate starts flowing down the proximal
tubule, its osmolarity is about 300 mOsm (same as that of
plasma). Glomerular filtrate is ISOTONIC to plasma.
- In the PCT, 65-70% of the total filtered Na+ and 65-70% of the
total filtered water is reabsorbed.
- Since same proportion of Na+ and water are absorbed from the
tubular fluid in the PCT, its osmolarity remains the same. That
is, tubular fluid remains ISOTONIC at the end of PCT
(osmolarity = 300 mOsm).
- Also note: Irrespective of the body’s water status or water
needs, 65-70% of the filtered water does get absorbed from
PCT. Hence, it is termed obligatory water absorption.
o Water absorption from the loop of Henle:
  The descending limb of loop of Henle is permeable to
water. 10-15% of the total filtered water is absorbed
from this segment.
 The thick ascending limb of loop of Henle is
impermeable to water. Na+, K+, and Cl- get absorbed
from tubular fluid in this part, but water is NOT
absorbed. Thus, in this segment, tubular fluid has less
solutes and relatively more water. Hence, this segment
is also called “diluting segment”.
 The fluid that leaves the loop of Henle and enters the
early distal convoluted tubule (DCT) is HYPOTONIC
(more of water relative to solutes).
o Water absorption in the DCT and collecting duct:
- As the filtered fluid reaches this segment of the nephron,
almost 85% water has already been absorbed from it.
- Once water is absorbed from this segment, final urine
composition (its water content) will be decided.
- Water reabsorption from this segment is dictated by the
body’s current water status and water needs. If body needs
water or plasma has become hypertonic (more solutes relative
to water), water will be absorbed from the DCT and CD into
blood.
- If plasma is hypotonic (more water relative to solutes), then
water will NOT be absorbed from this segment (or absorbed
minimally).
- Hence, water reabsorption by this part of the nephron is called
facultative water reabsorption (water reabsorption according
to body needs).
 Facultative water reabsorption from DCT and CD is regulated by the
antidiuretic hormone [ADH].
- If plasma is hypertonic → water needs to be reabsorbed into
blood;
 Hypertonic plasma is sensed by the osmoreceptors in
hypothalamus → release of ADH from posterior pituitary →
ADH reaches kidney → causes antidiuresis (water reabsorption
from DCT & CD).
- Mechanism of action of ADH:
ADH causes insertion of aquaporin channels in the tubular
wall. Water absorption from tubules is facilitated; it occurs
through these aquaporins.
- Note: In the absence of ADH – 2 to 3% of water is absorbed by
this segment. Thus, [85% water absorbed from earlier
segments] + [2-3% absorbed from DCT & CD] ≈ 88% water will
be reabsorbed from the glomerular filtrate; remaining will
form the urine volume.
- In the presence of ADH – 10 to 12% of water is absorbed from
this segment. Thus, [85% water absorbed from earlier
segments] + [10-12% absorbed from DCT & CD] ≈ 97% water
will be reabsorbed from the glomerular filtrate; remaining will
form the urine volume.

~ Some other tubular functions:

 Proximal tubule: {Reabsorption and secretion}

1. Handling of the filtered HCO3-:

- Plasma HCO3- = 24 mEq/L. GFR = 180 L/day. Total filtered

amount of HCO3- = (Px × GFR) = 4320 mEq/day.

- All of this bicarbonate has to be reabsorbed and taken back

into the body under normal circumstances.

- This bicarbonate is reabsorbed from the PCT.

 - It can be reabsorbed only when it first combines with H+ ions in
the tubular lumen. Hence, to facilitate the absorption of HCO 3-,
4320 mEq of H+ is secreted every day by the PCT.

2. Glucose and amino acids:

- Glucose and amino acids are completely reabsorbed from the

proximal tubule.

 By the end of the proximal tubule:

- Only 1/3rd of the filtered Na+, water, and K+ are left (2/3rd or
67% reabsorbed)

- Almost all of the filtered glucose, amino acids, and HCO3- have
been reabsorbed.

- Many solutes destined for excretion (e.g. urea) have been

concentrated.

o The proximal tubule secretes organic ions:

 Proximal tubule secretes a large variety of organic cations and

organic anions; many of them are endogenous substances, drugs, or
toxins.

 The organic anion transporter (OAT) in the wall of the proximal

tubule causes active secretion of anions such as – penicillin, PAH,
creatinine, etc.

 The organic cation transporter (OCT) causes active secretion of

cations. E.g. creatinine.

[Creatinine is an unusual compound, because it is secreted by both

anion & cation transporters. The creatinine molecule bears both
negatively charged and positively charged groups at physiological
pH; that is, it is a zwitterion.]
 o Proximal tubule also actively reabsorbs some organic cations & anions. E.g.
uric acid. Thus, uric acid is both reabsorbed as well as secreted in the
proximal tubule.

 Tubular transport in the loop of Henle:

- The loop of Henle reabsorbs about 20% of filtered Na+, 25% of

filtered K+, 30% of filtered Ca++, 65% of filtered Mg++, and 10-
15% of filtered water.

- Descending limb is highly water-permeable. Thick ascending

limb (TAL) is water-impermeable. TAL reabsorbs Na+, K+, Cl-.

- The NKCC transporter is present in the thick ascending limb. It

is sodium/potassium/chloride co-transporter; 1 Na +: 1 K+: 2 Cl-
are transported by NKCC (thus, it is electroneutral).

 Cortical collecting duct is an important site that regulates K+ excretion:

There are two types of cells in the collecting duct:

a. Principal cells – reabsorb Na+ and secrete K+; and then

b. Intercalated cells – reabsorb K+ and secrete H+
 When dietary K+ is low, K+ is conserved in the body by kidneys. The
intercalated cells will reabsorb more K+.
 K+ secretion is promoted by the hormone aldosterone. It increases Na +
reabsorption and consequently, increases K+ secretion. When body K+ has
increased, aldosterone will exert these actions and eliminate K+ into urine.

~ Transport maximum or tubular maximum (Tm): [short note]

- It is the maximum rate at which a substance can be transported

across the tubules, either reabsorbed or secreted.
 - This limit is due to the carrier protein in the tubular wall. The carrier
protein for every substance has a finite capacity to transport a
particular substance. That is, it is saturable.

e.g. Tm for glucose (TmG) ≈ 320 mg/min. Glucose carrier can maximally transport
up to 320 mg of glucose from the tubular fluids into blood.

As the plasma glucose goes on increasing, filtered load of glucose also will
increase. [Filtered load = Px × GFR; thus, greater the plasma level – Px – greater
will be the filtered load of that substance.]

As the filtered load increases, reabsorption will also increase. However, beyond a
certain level, the reabsorption can not increase further. Reason: The carrier which
causes the transport and reabsorption of glucose will get completely saturated.

The extra amount of glucose, over and above the maximum capacity of the
transporter (TmG) will begin to appear in urine.

Note:

Renal threshold for glucose = 180 mg%. That is, when plasma glucose
exceeds 180 mg%, glucose begins to be excreted in urine. [Below this plasma level
of glucose, all the filtered glucose is reabsorbed; none appears in urine.]

If the tubular transport maximum (Tm) for glucose is 320 mg/min., tubules have
the capacity to reabsorb glucose @ 320 mg/min. Then, when plasma level
exceeds just 180 mg%, why all of the filtered glucose cannot be reabsorbed and
some begins to appear in urine?

Answer to this question is: Heterogeneity among the nephrons in their filtration
capacity and reabsorption rate. Different nephrons have different capacities to
filter and then reabsorb glucose load.

Some nephrons may have a large glomerulus but a short proximal tubule. Such
nephrons will cause glucose to appear in urine at a low plasma level of glucose.
Reason ~
 - Large glomerulus → means it can filter greater amounts of glucose
per unit time.

- Short length of proximal tubule → means less number of glucose

transporters to absorb the filtered load of glucose. The transporters
saturate early and the remaining glucose begins to appear in urine.

Sodium reabsorption along the entire nephron, and potassium secretion

along the distal nephron do not have a Tm value.

-------------------------------------------------------------------------------------------------------------

~ Mechanism of urine formation: [LAQ] {Steps in urine formation}

[This answer may have many repetitions from the previous discussion. However, it
is given again separately here, so that it will be convenient to answer this
particular question.]

o About 1 to 1.5 L urine is formed every day.

o Urine formation involves 3 steps:

1. Glomerular filtration (or ultrafiltration)

2. Tubular reabsorption

3. Tubular secretion

(1) Glomerular filtration:

- As blood enters the glomerulus via the afferent arteriole, a filtrate is

formed from the plasma. This filtrate is free of proteins. The remaining
blood leaves the glomerulus via the efferent arteriole.

- Normally, the afferent arteriole is short and wide, and the efferent
arteriole is long and narrow. Hence, the blood cannot leave the
glomerulus at the same rate that it enters the glomerulus. This relative
 resistance for the blood to flow out of the glomerulus creates the
filtration force or hydrostatic pressure.

- The glomerulus is a tuft of capillaries. Most substances are filtered from

these capillaries; this filtrate then enters the Bowman’s capsule.
Capillary endothelium has many pores called “fenestrae”; filtration
occurs through these fenestrae.

- The filtration membrane has many layers (such as endothelium of the

glomerular capillary, basement membrane of the capillary endothelium,
etc). Plasma proteins are negatively charged, and the filtration
membrane also has negative charges on it. Hence, it does not allow
proteins to be filtered.

- Glomerular filtration rate (GFR): It is the amount of filtrate formed by

the kidneys in a minute.

Normal GFR ≈ 125 mL/min., that is, 180 L/day.

GFR is measured by using following substances:

(i) Inulin (exogenously administered)

(ii) Creatinine (endogenous substance)

- Renal blood flow ≈ 1250 mL/min.; renal plasma flow (RPF) would be: 625
mL/min. (approximately). Out of this plasma flow per minute, 125 mL
filtrate is formed. Hence, “filtration fraction” = GFR/RBF = 20% or 0.2.

- Factors that favor filtration are: Glomerular capillary hydrostatic

pressure. It is about 60 mm Hg.

- Factors that oppose filtration are: (1) Plasma colloid osmotic pressure
(32 mm Hg), and (2) Bowman’s capsule hydrostatic pressure (18 mm
Hg). Total opposing force = 32 + 18 = 50 mm Hg.

- Hence, the “net” filtration pressure = 60 – 50 = +10 mm Hg.

 - Capillary filtration coefficient ≈ 12.5 mL/min./mm Hg. {For every 1 mm
Hg filtration pressure → capillaries filter 12.5 mL per minute.}

- Since total net or effective filtration pressure is 10 mm Hg, total filtration

would be: 12.5 × 10 = 125 mL/min.

(2) Tubular reabsorption:

o 180 L of filtrate is formed every day. However, the final urine

formation is only about 1-1.5 L/day. It means, the remaining almost
178.5 L of filtrate is reabsorbed by the tubules.

a. Proximal tubular reabsorption:

 When the glomerular filtrate is formed, it is isotonic to

plasma (300 mOsm). This isotonic filtrate enters the
proximal tubule.

 65-70% of Na+ in this filtrate and 65-70% of water is

reabsorbed in the proximal tubule. Since same
proportion of Na+ and water are reabsorbed (and same
proportion of them are left behind in the tubular fluid),
tubular fluid at the end of proximal tubule is still isotonic
(300 mOsm).

 Remaining 30-35% Na+ and water enter the loop of

Henle.

 65-70% of the filtered K+ is reabsorbed in the proximal

tubule.

 All of the filtered glucose and amino acids are

reabsorbed from the proximal tubule.

 All of the filtered HCO3- is reabsorbed from the proximal

tubule. Major fraction of the filtered Cl- is reabsorbed
 from the PCT. Ca++ (60%) and Mg++ (25%) is reabsorbed
from the proximal tubule.

b. Reabsorption in the loop of Henle:

 15-20% Na+ is reabsorbed from the loop of Henle. The

remaining Na+ reaches distal nephron. All of the
remaining Na+ will be reabsorbed from the DCT and CD.

 Water reabsorption from the loop of Henle: The

descending limb of loop of Henle reabsorbs some 10%
water from the tubular fluids.

Thick ascending limb (TAL) of loop of Henle is

impermeable to water.

Since water is not reabsorbed from the TAL, tubular

fluids become hypotonic. This segment of the nephron is
hence called “diluting segment”.

 25% of the filtered K+ is reabsorbed in the loop of Henle.

Some amount of Cl- is also reabsorbed from the thick
ascending limb of loop of Henle.

 Ca++ (20%) and Mg++ (65%) are reabsorbed from the loop
of Henle.

c. Reabsorption from the distal nephron:

 Water reabsorption from the DCT and CD is under the

regulation of ADH. Depending on the osmolarity of plasma,
ADH will reabsorb water from the tubular fluids. The
remaining water will be finally excreted in urine, with
solutes dissolved in it.

 Collecting duct has two types of cells: (1) Principal cells –

They reabsorb Na+ and secrete K+; (2) Intercalated cells –
They reabsorb K+ and secrete H+.
  Ca++ reabsorption in the distal nephron is under the
influence of the parathyroid hormone.

(3) Tubular secretion:

- H+ ions are secreted in the PCT. This secretion is to facilitate

reabsorption of the filtered HCO3-.

- Proximal tubule secretes many organic ions; endogenous substances

(e.g. creatinine), toxins, and drugs are secreted by this segment.

- Uric acid can be secreted as well as reabsorbed from the proximal

tubule.

- H+ ions are secreted by the intercalated cells in the collecting duct. This
secretion is to achieve acidification of urine (to remove excess acids in
the conditions of acidosis of plasma).

- K+ can be secreted as well as reabsorbed from the distal nephron.

Whether net secretion or net reabsorption occurs would depend on the
K+ status of the body. In the conditions of hyperkalemia, net K + secretion
would occur (via the principal cells).

------------------------------------------------------------------------------------------------------------

~ Mechanism of formation of concentrated urine: [LAQ]

The human kidney can form concentrated urine; maximum urine osmolality
is upto 1200 mOsm/L of water. (or, in other words, 1200 mOsm solutes can be
excreted in just 1 Liter of urine volume.)[Note that: osmolality of plasma ≈ 300
mOsm]

Why is it important to be able to form concentrated urine?

“The ability to form osmotically concentrated urine is an important adaptation
to life on land.”

Concentrated urine, or hyperosmotic urine, excretes the solutes but conserves

water in the body. Just adequate amount of water will dissolve the solutes to be
excreted in urine.

Let us take an example.

The kidneys have the task of getting rid of excess solutes or waste products (e.g.
urea, creatinine, etc.) A minimum of about 600 mOsm of solutes have to be
excreted per day.

If we were only capable of excreting that is isotonic to plasma (≈ 300 mOsm/L of

water), then we would need to excrete 2 L of water/day (to excrete 600 mOsm
solutes).

However, human kidneys have an ability to form concentrated urine up to 1200

mOsm/L. It means, only ½ L of water will be excreted per day (to eliminate 600
mOsm of solutes). Thus, by excreting solutes in osmotically concentrated urine,
the kidneys effectively save 1.5 L water for the body.

 Two important determinants in the formation of a concentrated urine are:

(1) Hyperosmolarity of the medullary interstitum, and

(2) Role of ADH.

Let us recall that:

Kidney has two types of nephrons:

(i) Cortical nephrons (85%) – located entirely within the renal

cortex; they short loops which are present within the cortex.

(ii) Juxtamedullary nephrons (15%) – the glomeruli of these

nephrons are located at the junction of cortex and medulla;
these nephrons have long loops which run through the cortex
all the way up to renal papilla.
 * Diagrammatic representation of
cortical and juxtamedullary nephrons.
15% of the nephrons are
juxtamedullary. Their glomeruli are in
cortex, just adjacent to medulla.
The juxtamedullary nephrons have long
loops of Henle that almost reach the
renal papilla.
Medullary interstitium is the part of the
medulla outside these long loops.
Tubular function of the long loops of
Henle
MEDULLA

CORTEX

o First step in the formation of concentrated urine is creating

“hyperosmolarity in the medullary interstitium”. Solutes are conserved
and accumulated in the medullary interstitium to create a hyperosmolarity.
When this happens, the tubular fluids then can achieve osmotic
equilibrium with the medullary fluid; that is, even the tubular fluids can
achieve the same hyperosmolarity. Hyperosmolar tubular fluids will
eventually form hyperosmolar (concentrated) urine.

o Hyperosmolarity of the medullary interstitium is achieved by the

juxtamedullary nephrons.

o Hyperosmolarity of the medullary interstitium is:

- Established by “countercurrent multiplication” and urea recycling,

and
 - Maintained by “countercurrent exchange” in the vasa recta.

The long loops of Henle (of juxtamedullary nephrons) are the ‘countercurrent
multipliers’;

Vasa recta (blood vessels along the loops) are the ‘countercurrent exchangers’.

 Countercurrent multiplication in the loop of Henle:

 The countercurrent flow is an important aspect in formation of

concentrated urine.

The diagram shows the

movement of tubular fluids.
Fluid goes down in the
descending limb of loop of
Henle, then travels in the
opposite direction in the
ascending limb. Then, it again
travels in the opposite
Descending direction in the collecting
limb Ascending
duct. This type of flow is
limb
called “countercurrent flow”
of tubular fluid.
Collecting
duct

 The countercurrent flow of fluid allows the reabsorbed solutes to

accumulate in one region. The fluid flows in opposite directions; it
helps to increase the osmolarity of the medullary interstitium.
 Countercurrent multiplication:
- The events start in the THICK ASCENDING LIMB of loop of Henle.
- Thick ascending limb (TAL) of loop of Henle is impermeable to water.
 The diagram shows thick
ascending limb of loop of
Henle. This part is
200 impermeable to water.
mOsm It contains the NKCC
400 transporter (Na+-K+-Cl-
Thick
mOsm cotransporter). Na+, K+, and Cl-
400 ascending limb
are transported from the
NKCC tubular lumen into the
interstitium.
Medullary
interstitium

- The NKCC transporter causes solutes – 1 Na+: 1 K+: 2 Cl- - to be

transported into the interstitium.
- Since thick ascending limb is impermeable to water, water was left
behind in the tubular fluid and solutes (Na+, K+, Cl-) are transported
out into the interstitium. Hence, tubular fluid in the thick ascending
limb becomes hypotonic (200 mOsm) and interstitium begins to
become hypertonic (400 mOsm).
- The descending limb will now go into osmotic equilibrium with the
medullary interstitium, by movement of water from the descending
limb into the interstitium. Hence, osmolarity of the tubular fluids in
the descending limb will also increase (400 mOsm).
- Now, new filtrate (with solutes) comes from the glomerulus. The
hypertonic fluid in the descending limb will be pushed forward into
the ascending limb. Thick ascending limb will again reabsorb solutes
from it into the interstitium; medullary interstitium osmolarity will
further increase (600 mOsm).
- Again the descending limb will try to equilibrate with the medullary
interstitium (600 mOsm). Again, new filtrate will be added from the
glomerular filtration. The fluid in the descending limb will move
forward into the ascending limb; thick ascending limb will reabsorb
more solutes from it, and so on.
- Maximum osmolarity achievable in the medullary interstitium is
about 1200 mOsm/L (roughly 4 times the plasma osmolarity). Hence,
tubular fluids can also achieve maximum osmolarity up to 1200
mOsm/L. Hence, maximum concentrated urine is also up to 1200
mOsm/L.
 Role of urea:
As descending limb of loop of Henle tries to achive osmotic
equilibrium with medullary interstitium, it does so by causing water
movement from the descending limb into the interstitium (osmosis).
This will increase the osmolarity of descending limb fluid, but since
water is going in the interstitium, osmolarity of interstitium may
decrease. This is where urea plays its part in maintaining the
hyperosmolarity of the interstitium.
Urea travels in the tubular fluids but is not absorbed from the
proximal naphron.
Urea is absorbed from inner medullary collecting duct. It enters the
medullary interstitium and maintains hyperosmolarity there.
 Urea recycling: From the interstitium, urea will again enter the
tubular fluids (ascending limb), will reach the collecting duct
and then again reabsorbed into the interstitium. As urea was
not reabsorbed in earlier part of the nephron, it gets
concentrated as it reaches the collecting duct. It gets further
concentrated due to the recycling. This helps in the body
economy. Urea is a waste product. It has to be excreted. But
before it is excreted, it gets concentrated and imparts
hyperosmolarity to the interstitium, thus helping in formation
of concentrated urine. [Urea has to be excreted in urine. If it
was not recycled and concentrated, and was straightaway
 excreted in urine, then its excretion would require a lot of
water. Thus, excess water would be excreted in urine.]
 urea recycling contributes about 40-50% to the total
osmolarity of interstitium. From interstitium it is transported
back to nephron, and again reabsorbed.
 “Countercurrent exchange”: Role of vasa recta

Ascending Descending The diagram shows the loop of

limb limb Henle with the vasa recta. (recta =
straight). The vasa recta are straight
long blood vessels with two limbs
and U-shaped bend. The blood flow
in vasa recta is in OPPOSITE
direction to that of the flow of
tubular fluids in the loop of Henle.

- Blood flow in the vasa recta is in opposite direction to that of the

flow of tubular fluids in the loop of Henle – the “countercurrent
flow”.
- Blood flows down in the descending limb of the vasa recta; this
descending limb is adjacent to the ascending limb of loop of Henle.
And then, blood flows up in the ascending limb of vasa recta; this
limb is adjacent to the descending limb of loop of Henle.
- Due to the long length of the vasa recta, blood flow in them is
sluggish. Due to the slow blood flow here, the solutes reabsorbed
 from the loop of Henle are not washed off from the interstitium.
Sluggish blood flow helps to maintain the hyperosmolarity of the
medullary interstitium.
- Exchanger mechanism:
o As blood flows down in the descending limb, it takes in the
solutes that have entered the interstitium and gives out water.
Thus, as the blood flows down, its osmolarity goes on
increasing. At the very tip of vasa recta (at the U-bend),
osmolarity will be maximum – 1200 mOsm/L.
o As the blood flows back upward in the ascending limb, it gives
out the solutes to the interstitium and takes the water back
into the blood vessel. Thus, the osmolarity of blood will go on
decreasing in the ascending limb.
o Due to this type of exchange (of solutes), the vasa recta
maintain the solutes in the interstitium, thus helping the
hyperosmolarity of the medullary interstitium.
 In short, vasa recta do not contribute to the hyperosmolarity of the
medullary interstitium; it only prevents the dissipation of the
hyperosmolarity (only helps to maintain the hyperosmolarity).

~ Role of ADH: (In formation of concentrated urine)

 Tubular fluids leave the loop of Henle and reach the distal convoluted
tubule. Since the thick ascending limb of loop of Henle was impermeable to
water, tubular fluid that leaves the thick ascending limb and enters DCT has
more water (hypotonic).
 ADH removes water from the tubular fluid in the late distal tubule and
collecting duct until its osmolarity equals that of surrounding interstitial
fluid. Final urine osmolarity is determined by this ADH action.
  Maximal hypertonic urine (or maximum urine concentration) can be 1200
mOsm/L (or 4 times the plasma osmolality).
 Most hypotonic (or dilute)urine may be 30 mOsm/L (or 1/10th of the plasma
osmolality).
A dilute urine means more water relative to solutes (hypotonic urine).
Dilute urine excretion occurs when water load in plasma has increased.
Plasma becomes hypotonic. It is sensed by hypothalamus, and secretion of
ADH is stopped. Diuresis occurs and water is lost in the urine.

 A young healthy adult has to excrete at least 600 mOsm of solutes every
day. Since maximum concentrating ability of kidney is 1200 mOsm/L, to
remove 600 mOsm solutes at least ½ L urine will have to be formed. Thus,
obligatory urine output would be ½ liter per day (to eliminate 600 mOsm
with most concentrated urine).
 And, with most hypotonic urine, maximal urine output would be 20 L/day.
-------------------------------------------------------------------------------------------------------------
~ Urinary bladder and micturition: [short notes – Micturition reflex;
cystometrogram]

 Urine is an excretory product formed every minute. However, it will be

very inconvenient to excrete it every now and then. Hence, urine is first
collected in the sac called urinary bladder. Then, with a suitable time and
place certain amount of urine is excreted out. Micturition is the process of
voiding of urine from the bladder.

 Urine collected in the urinary bladder is excreted out via urethra.

 Daily urine excretion ≈ 1-1.5 L.

 Functional anatomy of urinary bladder:

- Urinary bladder wall consists of:

1. Stretch receptors – They convey the stretch of the bladder wall

due to filling of urine,

2. Detrusor muscle – Contraction of this muscle causes emptying of

the bladder.

- There are two sphincters at the base; these sphincters regulate the
flow of urine into the urethra:

(1) Internal urethral sphincter – It is a smooth muscle; under

autonomic control.

(2) External urethral sphincter – It is a striated muscle. Under

voluntary control, it is innervated by pudendal nerve. Voluntary
control of the process of urination is provided by external
sphincter.

 Innervation of the bladder -

- Parasympathetic nerves that control the bladder: S2,3,4. (nervi
erigentes or pelvic nerves; control detrusor muscle and
 internal urethral sphincter). These nerves form a reflex arc
from the bladder wall to the spinal cord and back to bladder.
- Sympathetic nerves: hypogastric nerves; convey pain sensation
from the bladder.
- Pudendal nerve: somatic nerve; controls external urethral
sphincter (a striated muscle). Neurons are located in the
“Onuf’s nucleus” in the spinal cord.
 Micturition centers in CNS:
1. Spinal cord: S2,3,4. It is the center for micturition reflex.
Afferent nerves arising from the bladder wall convey the
signals about the stretch of the bladder wall (filling of the
bladder) to this spinal cord center. The efferents from
spinal cord will then reach the bladder; they will cause
detrusor contraction and relaxation of the internal urethral
sphincter.
Also, when the signals about bladder stretch reach the
spinal cord (S2,3,4), they are conveyed to the brain stem
center.
2. Brain stem (pontine) center: called “Barrington’s center”; it
is an integrating center for the process of micturition. It
receives signals from the bladder (regarding the bladder
wall stretch) and conveys them to the cortex.
This center consists of both facilitatory and inhibitory
groups of neurons which either facilitate or inhibit the
sacral center for micturition; thus exerting control over the
micturition reflex.
3. Voluntary center: situated in paracentral lobule in frontal
lobe. It is mainly an inhibitory center. It exerts an inhibitory
influence on the brain stem micturition center. As long as
the micturition is not desired, this center will inhibit the
facilitatory center in the brain stem; micturition can not
start. When micturition is desirable, this inhibition is lifted.
 Facilitatory center of brain stem will then facilitate the
reflex arc in the sacral segments and micturition can occur.
(Micturition reflex begins at 5th month of I.U. life when urine secretion
starts; voluntary control of micturition does not appear until the age of 2 ½
to 3 years.)
 Micturition reflex and the process of micturition:
- As the urine begins to be filled in the bladder, the bladder wall
begins to stretch.
- When about 100-150 mL is filled in the bladder, the stretch
receptors in the bladder wall begin to convey the impulses,
from the bladder, to the spinal cord (S2,3,4 segments).
- From the spinal cord segments, the signals are then
transmitted toward brain in the DORSAL COLUMNS of the
spinal cord. The sensations will reach the sensory cortex
(parietal lobe); sensations reach the consciousness.
- As the bladder continues to get filled further, the number of
impulses from bladder to spinal cord and from there to the
higher brain will gradually increase.
- If micturition is not desired at this stage, the frontal lobe
voluntary center will keep the brain stem center inhibited.
Brain stem center will keep the reflex arc from the bladder
inhibited.
- If and when micturition is desirable (with suitable time and
place) – The voluntary inhibition by the frontal lobe center will
be lifted. Now, the brain stem facilitatory center will initiate
the signals to facilitate the reflex arc from the bladder. The
process of micturition can begin.
 Micturition reflex is a “self-regenerative process”. That is, it occurs as a
“positive feedback” cycle. It starts as a weak signal, and gradually becomes
stronger and stronger by positive feedback.
 Signals from bladder wall reach spinal cord (sacral segments). Via the
efferents of the reflex arc, signals run back to the bladder.
 First event in the micturition reflex is detrusor contraction. The internal
urethral sphincter will relax. A series of events will be initiated.
 First few drops of urine enter posterior urethra. Dilatation of the urethra
will cause signals to arise from there to again go back to the spinal cord.
Detrusor contraction and relaxation of the external urethral sphincter will
follow.
 Urine will continue to flow down the urethra. Bladder contractions will
become stronger and stronger (positive feedback process), till the void
occurs.
 Toward the end of the micturition process, the reflexes abet; micturition
process becomes weaker and stops.
 About 50 mL urine is left in the bladder. It is called “residual urine”.

 NOTE:
- 100-150 mL urine in the bladder: first sensation of filling of
bladder
- 150 – 250 mL in the bladder: first desire/urge to void;
- 300-400 mL in bladder: initiates reflex contraction;
- 450 mL in bladder: urgency for micturition;
- 750 mL in bladder: painful urgency for micturition.

 Cystometrogram: [short note]

- It is a graphic depiction of the pressure-volume relationship in
the bladder. (increase the bladder pressure with increasing
urine volume in bladder; cyst = bladder)
 Pressure
in II
bladder
wall
(cm H2O)

Ib
Ia

100 200 300 400 450

Urine volume (mL) in bladder

The cystometrogram shows 3 phases:

1. Phase Ia – Volume in bladder upto 100 mL.
As the urine is filled in bladder, pressure in the bladder wall increases
gradually.
2. Phase Ib – [Laplace’s law]
The urinary bladder is a hollow sphere. Hence, it obeys Laplace’s law.

P = 2T/R; where P – pressure in the sphere, T – tension in the wall, and R –

radius of the sphere.
It indicates that the pressure in a hollow viscus is directly proportional to
the wall tension and inversely proportional to the radius.
From 100 mL to 400 mL urine getting filled in the bladder –
 Tension (T) in the wall increases, but radius (R) of the bladder also
increases. [Both numerator & denominator increase proportionately.]
Hence, pressure (P) in the bladder wall remains almost the same. As the
pressure in the bladder wall does not increase much, signals arising from
the bladder wall are not strong.
3. Phase II -
As about 400-450 mL urine is filled in the bladder, wall tension (T) increases
further but radius (R) cannot increase any further. (Denominator remains
constant but numerator increases). Hence, the pressure (P) in the bladder
wall will increase steeply now. Strong signals will be sent from the bladder
wall to the spinal cord and from there to the higher centers. There will be
urgency for micturition at this stage.

~ Applied physiology:

 Types of bladder: (effects of lesions at various levels)

1. Atonic bladder:
 Deafferentation; or lesion of the afferent nerves from bladder.
 Reflex contractions of bladder are abolished
 May be due to tabes dorsalis in which dorsal root nerve fibers
from bladder damaged – tabetic bladder.
2. De-centralized bladder:
 When both the afferents and efferents of bladder are damaged.
 Bladder is flaccid and distended; may become active gradually,
expels dribbles of urine
 May be caused by tumors of cauda equina or filum terminale.
3. Overflow incontinence:
 If the spinal cord is damaged above sacral segments, leaving reflex
pathway intact. Initially, “spinal shock” condition causes
suppression of reflexes; results in loss of bladder tone.
 Bladder becomes overfilled and exhibits sporadic voiding.
4. Automatic bladder:
  As the spinal shock wears off, micturition reflex returns but
without voluntary control. Periodic but unannounced emptying of
bladder.
5. Spastic neurogenic bladder or uninhibited bladder:
 Partial damage to spinal cord that interrupts inhibitory influences
from higher centers.
 Also, if there is a lesion in the brain between voluntary control
center (frontal lobe) and pontine center. Inhibition of the bladder
emptying is lost.
 Bladder capacity reduced and reflex hyperactivity occurs.
 Onset of micturition cannot be controlled voluntarily once the
reflexes are initiated; voluntary mid-stream holding not possible.

REGULATION OF ACID-BASE BALANCE

~ Acid is defined as any substance that adds H+ to the body fluids, whereas alkali
is defined as a substance that removes H+ from the body fluids.

CO2 derived from aerobic metabolism is termed volatile acid, since it has the
potential to generate H+ after combining with H2O.

{CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3-}

The Henderson-Hasselbalch equation is used to quantitate how changes in CO 2

and HCO3- affect pH.

pH = pK + log [HCO3-/(0.03 × PCO2)]

{pK is the pH at which the acid is half dissociated from its conjugate base.}

Excess addition of H+ to the body fluids is called acidosis; excess removal H+ from
the body fluids is referred to as alkalosis.

The defenses against changes in the H+ concentration:

 The 3 defense lines that regulate the H+ concentration in the body fluids
and prevent acidosis or alkalosis ~ (1) The chemical buffer system of the body
fluids, (2) The respiratory system, and (3) The kidneys. {Note that: These defenses
would react to a change in pH in the given order.}

(1) The chemical buffer system:

4. The first line of defense; these buffers react within seconds.
5. The 3 chemical buffers are bicarbonate, phosphate, and
intracellular proteins.
(a) The bicarbonate buffer system – (components ~ HCO3- &
H2CO3)
o Its pK is 6.1 {pK of a buffer system is the pH at or
around which the buffer system is most effective.}
Since the pK is 6.1, and pH of ECF is 7.4, the ratio
of [HCO3-]/[H2CO3] should be maintained at 20 for
a given pH 7.4 according to Henderson-
Hasselbalch equation.
o It is the most powerful buffer in the ECF.
Increasing plasma HCO3- increases the plasma pH.
o It is an important and effective buffer system
because the two elements of this system – HCO3-
& CO2 – are regulated precisely by the kidneys and
the respiratory system.
(b) The phosphate buffer system – (components ~ HPO4-- &
H2PO4-)
o Its pK is 6.8. {pH of ECF is 7.4 and intracellular pH
is slightly less.} The ratio of [HPO4--]/[H2PO4-]
should be maintained at 4, for a given pH of 7.4.
o It has a major role in buffering renal tubular fluid
and intracellular fluid.
(c) Proteins –
o Among the most plentiful buffers in the body;
they are the most important intracellular buffers.
 Reason: proteins are in high concentrations within
the cells and pKs of many protein buffers are fairly
close to 7.4.

o About 60-70% of the total chemical buffering of

the body fluids is inside the cells, and most of it is
by the proteins.
{Note that: Hemoglobin is an ECF buffer.}

(2) The respiratory system in acid-base regulation: (A “physiologic” buffer

system)
6. The second line of defense; it acts within a 3 to 12 minutes
to eliminate CO2 and thus H+ ions from the body. Increased
CO2 stimulates ventilation via formation of H+; H+ stimulates
the respiratory center and the resultant increase in
ventilatory drive washes-off the CO2 and H+. A decrease in
CO2 and H+ will have an opposite effect, that is, it decreases
the ventilatory drive.
7. It is more effective in a condition of decreased pH as
compared to that of an equivalent increase in pH.
8. Impairment of lung function may lead to “respiratory
acidosis” (increased CO2 & H+); excess ventilatory drive may
lead to “respiratory alkalosis”.
(3) Role of kidneys in acid-base balance:
9. Third line of defense; it acts slowly over hours-to-days.
However, the strongest acid-base regulatory system.
Kidneys regulate the H+ concentration by 3 basic
mechanisms – (a) Reabsorption of the filtered bicarbonate,
(b) Secretion of H+ into the tubules and its excretion, and
(c)Generation of new bicarbonate
(a) Plasma HCO3- is 24 meq/L, and GFR is 180 L/day. Thus, (24 ×
180 =) 4320 meq of HCO3- is filtered every day by kidneys.
 About 80% of it is reabsorbed from the PCT; 10% in the TAL,
and remaining in the distal nephron. Thus, kidneys conserve
the primary buffer system of the body.
(b) The HCO3- can be reabsorbed only after it reacts with H+ (H+ +
HCO3- → H2CO3 → CO2 + H2O, is necessary for movement across
tubular cells). Thus, 4320 meq of H+ will have to be secreted by
tubules. Plus, 80 meq of non-volatile acids are produced daily
from the metabolism of proteins. Hence, (4320 + 80 =) 4400
meq of H+ ions are secreted every day by renal tubules, almost
80-90% of this occurs in the PCT. H+ and HCO3- are “titrated”
against each other in the tubules. In acidosis, excess H+ will be
excreted into urine; in alkalosis, excess HCO3- is excreted.
Normally, about 50-100 meq of H+ (equivalent to the non-
volatile acids) is exreted in urine; urine is normally acidic.
[Removal of an H+ ion is the biochemical equivalent of addition
of a bicarbonate ion. Thus, H+ excretion is coupled with
generation of HCO3- in the renal tubules, to correct acidosis.]
(c) Excess H+ combines with urinary buffers ~ phosphate and
ammonia (NH3). These two buffers also generate new HCO3-
that can be added to blood in conditions of acidosis.
- Ammonia is synthesized from glutamine in renal tubular
cells; one molecule of glutamine produces two
molecules of ammonia and two HCO3- are added to ECF.
- Non-ionic diffusion: NH3 secreted by tubules combine
with H+ in the lumen to form NH4+; NH4+ now cannot
diffuse back into the tubular cell. Thus, NH4+ is trapped in
the lumen and excreted in urine, eliminating the H+.
- NH3/NH4+ is the buffer for chronic respiratory acidosis.
- H+ eliminated by phosphate buffer is called “titratable
acid”. The ratio of titratable acid to ammonia-buffered
acid is about 1: 2.5.
 Titratable acidity: In a condition of acidosis, there will be urinary
acidification. Acid excretion in the urine is due to the action of urinary
 buffers in the tubules. The urine sample is collected and is titrated against
NaOH, to bring the pH back to 7.4 (that is, the normal pH of blood). The
amount of alkali (NaOH) required in this reaction gives the amount of
titratable acids eliminated in the urine. It is mostly the acids buffered by
phosphate; creatinine, uric acid may also contribute. H+ combined with
ammonia is NOT included in titratable acidity. Reason: Of the two urinary
buffers, ammonia has a pK of about 9.2. It means, in the given titration
(from acidic pH to 7.4) ammonia buffer is not active. Thus, titratable acidity
can be said to be phosphate-buffered acid in urine.
 H+ secreted by the proximal nephron is combined with HCO3- and thus is
utilized for the purpose of HCO3- reabsorption. It means, this H+ does not
contribute in urinary excretion of acid. The major site for urine acidification
is the DCT and collecting duct. The H+ secretion here is against the
concentration gradient. It can create a gradient for H+ of about 1000: 1
between the tubular fluids and the plasma. This is the maximal H+ secreted;
it makes the urine pH about 4.5. This is called “limiting pH" of the tubular
fluids. And, the urine can be acidic up to this pH.

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