blue= Dr Saif notes Lecture Session

Pink= Dr Suzan notes

Water and electrolyte balance I Urine formation

Dr. Saif Ahmed MBBS , MD Dr. Suzan Hazzaa MD
Assistant Professor Associate Professor
Department of PHYSIOLOGY Department of PHYSIOLOGY
College of Medicine College of Medicine

D suzan Hazzaa

This is nephron,

In the nephron there is renal corpuscle that consist of

The glomerulus is a tuft of capillaries that receives its blood supply
1-Renal glomerulus and bowman’s capsule, and this is the place
corpuscle where glomerular filtration happen from afferent arteriole and drains into efferent arteriole.

Then the filtrate goes down to proximal tubule then

receive as Afferent arteriole then the formation of tuft of capillaries -glomerulus- then left the
descending loop of H then ascending loop of H then glomerulus as efferent arteriole then the capillaries will run with the tubules -capillaries
distal tubule then collecting duct. peritubulares- and then those capillaries will form Venus drainage

The kidney is consist of a lot of nephrons (the functional unit)

The most Imp component of the nephron are: 1-Glomerulus 2-Tubules
- Glomerulus consist of: tufts of capillary located inside Bowmans
capsule - the start of renal tubules - Efferent
arteriole

:
- Tubules: 1-proximal 2-loop of Henle (descending and ascending
Afferent
limbs) 3-distal 4-collecting duct arteriole

There is filtration happening,

some of the plasma leaks out from this

The blood takes U turn and go backwards

this side is Not water permeable

this side is freely (ascending loop of H, distal
tubule, part of collecting duct)
water permeable They can be water permeable
in the presence of ADH
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The main function of the nephron is to clean the blood from waste
2-Renal tubules products, excess water and excess electrolytes
Urine formation include the following processes:
If this process doesn’t happen, huge amount of filtration will be wasted
without any benefit

1- Glomerular filteration.
Whatever goes out from blood vessel = filtration
Whatever come back to blood vessels= reabsorption
2- Tubular reabsorption.
3- Tubular secretion. As the plasma filtered
out, many of the stuff
The stuff that the body don’t
want or want to git rid of —>
secreted from the blood to
has been filtered out the tubules
like glucose and amino
acid and various
Actively some
electrolytes, we want to of the stuff
Everything could pass this from the blood The body tries to
take them back we
“‫ﺻﻔﺎﯾﺔ‬،‫ ”ﻣﺼﻔﻰ‬except protein and RBCs don’t want to lose them. is pushed intro take back
-the large molecular weight- everything it
the filtrate
need from the

i
tubules by
reabsorption and
what isThe
leftbody
is tries
called urine
Afferent

Efferent
I

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 Glomerular filteration Glomerular Membrane
‫= ﻣﺎ ﺗﻘﺪر ﺗﺨﺘﺎر اﯾﺶ اﻟﺤﺎﻗﮫ اﻟﻠﻲ ﺑﺘﻌﺪي‬

GF is a non selective, passive It is the membrane through which the fluid is filtered from the
process. glomerulus to the Bowman’s capsule.
Very Imp to know that this membrane is highly permeable
Molecules can’t pass the glomerular filtration:
= ‫ﯾﻌﻨﻲ ﺑﯿﻌﺪي ﻛﻞ ﺣﺎﻗﮫ ﻣﺎ ﻋﺪا اﻟﻠﻲ ﻗﻠﻨﺎ ﻋﻨﮭﺎ‬
Glomerular filterate:
Glomerular

i
membrane

- RBCs
- plasma proteins

Is the fluid filtered from the

Glomerular
filtrate

glomeruli.
It contains all constituents of the
plasma minus its colloids
it is very similar
to plasma
except? (RBCs &plasma proteins).
r filtrate ‫ ﺣﺘﻨﺰل ﻓﻲ اﻟـ‬plasma ‫ ﻓﻲ اﻟـ‬dissolved ‫= ﻛﻞ ﺣﺎﻗﮫ‬
x

Waste products and useful materials are

dissolved in plasma. "
There will be stuff in the filtrate like waste products we will not take them back.
Still all the waste prducts has not been filtered out, there will be waste products still
carried in the blood so we can forcely by using energy put them back in the filtrate.
And both of them will be filtered out in the filtrate but the useful products will this is known is secretion. Number 3 in pic
be taken back to the blood vessels (reabsorption) Number 2 in pic
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Permeability of the glomerular membrane: Glomerular is a type of capillary,

but its permeability is very high

It is about 50 times the permeability of skeletal muscle capillaries. Its

permeability is selective and depends on:
Factors affect the transportation: Glomerular filteration rate (GFR):
1- size of the molecule; the smaller the molecule the easier its passage.
It is the volume of the fluid filtered by glomeruli of both kidneys per
Molecules up to 8 nm can pass easily.
* a
unite time. MCQ *
*
Glomerular
membrane

2- Electric charge of the molecule; negative charge of the GM repels

Normally it is 125ml/minute or 180L/day. 178L/day are reabsorbed back
So we are left with 2L and that is the

negatively charged molecules like plasma proteins. Albumin is about 6nm into the blood stream. amount of urine we make everyday

in diameter but can not pass because of its negative charge. Like Like magnet:
magnet

3- shape of the molecule; long spherical molecule pass more easily than
spherical one.

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G Filtration is passive process

filteration pressure:
Forces oppose the filtration The plasma will try to put pressure and move back intro the
It is the some of all hydrostatic and osmotic pressure that occurs across capillaries, this is called bowman’s capsule Hydrostatic pressure

the glomerular membrane. 1- Hydrostatic pressure in Bowman’s capsule. It is about 18mmHg.

2- Colloidal osmotic pressure in glomerulus. It is about 32 mmHg.
Forces help filtration There are proteins in the plasma of glomerulus capillaries, so the water in
arterial blood pressure ‫ ﻣﻌﺘﻤﺪه ﻋﻠﻰ اﻟـ‬mainly the bowmans capsule will tend to move intro the capillaries
‫ ﯾﺰﯾﺪ‬glomerular hydrostatic pressure ‫ﻛﻞ ﻣﺎ ﯾﺰﯾﺪ ﺿﻐﻂ اﻟﺪم ﻛﻞ ﻣﺎ اﻟـ‬

1- Glomerular hydrostatic pressure. It is about 60mmHg.

The plasma protein is concentrated
2- Colloidal osmotic pressure in Bowman’s capsule. Thecolloidal
so the plasma protein
osmoticispressure
concentrated
is

r
high

It is about 0 mmHg.
Water loves and get attracted to
proteins, but there is no proteins
in the bowman’s capsule so the
pressure is 0

absorption force ‫ ﻓﯿﻌﻄﯿﮫ‬،‫ ﻧﺎﺣﯿﺘﮫ‬fluid ‫ ﻓﻲ ﻣﻜﺎن ﯾﺴﺤﺐ اﻟـ‬protein ‫وﺟﻮد اﻟـ‬

There are no protiens in

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60 =0+60 =‫ﻣﺤﺼﻠﺔ اﻟﻘﻮى‬
Colloidal bowmans capsule
because there are no
op = zero protein is filtered out,
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So will be there colloid
osmotic pressure? NO
 Net filtration forces At the level of glomerulus The net filtration is the difference between the
filtration force - the absorption force = 10 mmhg
Total

Renal handling of
water
Take
back
Filter out into BV

= (60+0) – (32+18) =

60 – 50 = 10 mmHg filtration ‫ﻟﺼﺎﻟﺢ اﻟـ‬

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Kidney is the most important organ in regulation of water Water reabsorption variable amount depends on
situation 1:
1-i took 1L juice, I am in situation in water excess or deficient? Water excess
2-filtration will happen 85% i will take them back for sure the ADH in the DCT & CT.
balance 3-for the remaining 15% i will take them or not it depends on secretion of ADH,
since I am in water excess after drinking 1 L, will the plasma osmolarity will be high
or low? low because my plasma is diluted.
4-if plasma osmolarity is low there will be no osmoreceptor getting activation -> no 2
secretion of ADH, ADH is the man that will open the water gates here, so no ADH it Water not permeable Regulatory or control part
will be water impermeable and no water is taken back, i will lose 15% of water in
the urine. Except under the .‫ﯾﻌﻨﻲ ﻋﻠﻰ ﺣﺴﺐ ﺣﺎﺟﺔ اﻟﺠﺴﻢ‬
Water permeable ‫ھﻞ اﻟﺸﺨﺺ ﯾﺸﺮب ﻣﺎء ﻛﻮﯾﺲ؟ اذا اﯾﮫ = ﻣﺎ اﺣﺘﺎج‬
Normally GFR is 180L/day, 178L/day are reabsorbed back Did the juice uptake affect the obligatory
water reabsorption? NO
‫ راجعه راجعه‬٪٨٥ ‫ كذا‬7‫هو هذا و‬
65+20=85%
affect of ADH 15% ‫ اذا ﻻ او ﺻﺎﺋﻢ‬.‫اﻟﻤﻮﯾﺔ اﻟﻠﻲ ھﻨﺎ وراح ﯾﺨﻠﯿﮭﺎ ﺗﻨﺰل‬
‫ﻣﻌﻨﺎھﺎ اﻟﺠﺴﻢ ﻣﺤﺘﺎج ﻟﮭﺎ وراح ﯾﻤﻨﻊ ﻧﺰوﻟﮭﺎ‬
ADH = ‫اﻟﻠﻲ ﯾﺘﺤﻜﻢ ﻓﻲ ھﺎﻟﺠﺰء‬

into the blood stream. Special arrangement

(‫ري فيها ارتري وارتري‬+‫)الكابي‬

Only 1:2 L/day are excereted

as urine.
a It is an obligatory water reabsorption USMLE Q:
1-osmolarity?
2-level of ADH?
This is a very nice diagram
this is how step exam asks
65% of filtered water is 3-level of urine formation?
4-If ADH is present urine produced will be
high in volume or low? LOW in volume

Which of the following a process of filtration? A reabsorbed in PCT.

P obligatory water reabsorption
Which of the following is a process of reabsorption? B Most part of reabsorption
Situation 2:
20% in the descending limb
Which of the following is process of secretion? C 1-In ramadan we are fasting, at Aser time we have been working we have been
switting we are passing urine we have lost some amount of water from our body, the
plasma osmolarity will be high or low?
High
of loop of Henle.
2-I am in water deficient state, will the obligatory filtration happen normally? Yes
3-in the other 15% i want the water gate to open and take the awter back, as the
plasma osmolarity is high it will be sensed by osmoreceptor and that will stimulate the
D suzan Hazzaa ADH secretion, this ADH will open the water channels “Aquaporins” and it will be taken
back to the body
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Types of water reabsorption Water input and output

Water input equals water output = 2.5 liters/day.
Obligatory means that ‫زم‬7 water that is filtered should be taken back

Obligatory water reabsorption: 80:85% of filtered water is reabsorbed in Water input:

response to pressure gradient. 1. Water intake from food and water.
It occurs in the proximal convoluted tubules and descending limb of loop of 2. Water released from oxidation of metabolism
Henle.
Water output:
Fucltative water reabsorption: Variable amount of water is reabsorbed
OR regulatory 1. Insensible water loss from the skin and lung by evaporation.
depending on the presence of ADH.
2. Sweating in high temperature.
ADH is secreted in response to change in the osmolarity of the blood. Abnormal conditions
3. GIT secretions increased in vomiting and diarrhea.
It occurs in late distal convoluted tubules and collecting ducts.
4. Kidney adjusts water loss.
Depends on state of water on the body.
Which part of kidney responsible for this? ADH

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Glomerular filtrate has the same osmolarity as plasma = 300
Because its a non selective so the water and electrolytes will be the same with the plasma

mosmol/L
Kidney can excrete as
much as 20L/day of diluted urine. Requirements for water
In case of excess water intake

reabsorption by the kidney

https://youtu.be/pcYrMI8fzqo

Kidney can excrete Water freely

permeable
N ADH
No water
https://youtu.be/xJag17JYF-I
here
In case of dehydration, fasting

concentrated urine up to
1200 – 1400 mosmol/L
Osmolarity of urine

We can pass very concentrated urine also if required

Diluted = water is more than salts
Concentrated = salts are more than water D suzan Hazzaa D suzan Hazzaa

1- Hyperosmotic renal medulla

The descending limb is impermeable to salts and very
permeable to water. It absorbs about 20% of filtered
water.
In the thick segment of the ascending limb of loop of henle
there is active transport of Na with cotransport of K
Water reabsorption and cl. But this segment is impermeable to water
The tubular fluid become progressively diluted in the tip of

Think of situation we have

the ascending segment.
very high osmolarity here,
so most of the water will The filtrate remaining here will
pulled out from the filtrate be high osmolatiry
In the thin segment there is passive reabsorption of Nacl
Following the salts —> high
salt concentration will pull
the water toward it and also it is impermeable to water

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2- High level of ADH 1- it increases permeability to water in DCT and collecting tubules by stimulation of
More ADK > more water taken back into capillaries
aquaporin 2 in the cell membrane and increase its gene transcription.
It is secreted by the hypothalamus and stored
2- it increase permeability to urea in the medullary collecting tubules.
in the posterior pituitary gland.
It acts on DCT of the kidney: increases water
reabsorption

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 Diagram shows you how urea contributes to it

3- Urea cycle
The kidney and water balance (Summary)
It contributes to 40% of renal
medullary osmolarity. Remember!
The ascending limb of loop of henle
•A disturbance in water balance results in Changes in
and collecting ducts are
plasma and ECF osmolarity
Extracellular fluid
impermeable to urea.

•Following water intake, the kidneys restore water balance

in presence of ADH water is reabsorbed
by merely excreting the water. Extra 1L of juice, kidney throw it into urine,
how? No ADH secretion

and urea.
Urea helps in water reabsorption
Urea can be put in medulla, it makes hyper-
osmotic environment right here.
Once the enviroment is hyper-osmotic so the
water can be taken.
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•When water is lacking, the kidneys excrete as little water as
possible but they alone cannot restore water balance.
•The thirst mechanism is also required.
if someone is running short of water, Kidney can
excrete less volume of concentrated urine.
The question is why doesn’t kidney stop making
urine for awhile?
Kidney can’t stop because it have to excrete the
waste products

Disorders of urinary concentration

1- Central Diabetes insipidus: More volume of urine

Less ADH Diagnosing Diabetes Insipidus

Abnormality in the ADH release or secreation from the posterior pitutary.
Ask px not to drink water after Asha, and
comes in the morning to the clinic.
2- Nephrogenic Diabetes insipidus: In the morning we will ask him how was the
night, how many time he went to the
Less insulin
bathroom.
-6 to 7 times -> DI
There is normal ADH level but the renal tubules can not respond appropriately. - only maybe once -> psychologic disorder
Problem in kidney

Symptoms:
1- polyurea.
2- polydepsia. We give ADH $

D suzan Hazzaa If problem in pituitary If symptoms is the same,

symptoms will improve the problem is in kidney

Central DI Vs Nephrogenic DI
Best of luck
Sara Alzharani
At night Rawan alrehaili

• THANK YOU..
• Queries invited:
saifahmed.2k7@gmail.com
Even if you asked the px not to drink water for the night, he
would still go and urinate