Editorial
Critical Role of Urea in the Urine-Concentrating Mechanism
Jeff M. Sands
Emory University School of Medicine, Renal Division, Atlanta, Georgia
J Am Soc Nephrol 18: 670 – 671, 2007. doi: 10.1681/ASN.2006121314
T
he ability to produce concentrated or dilute urine al-
lows people to vary water excretion to match water
intake, thereby maintaining a nearly constant blood
plasma osmolality. This is accomplished in the renal medulla
through the combined actions of several transport proteins in
the loops of Henle, collecting ducts, and vasculature and the
complex but unique spacial relationship that these structures
have to each other. In the outer medulla, active NaCl reabsorp-
tion by the Na-K-2Cl co-transporter in the thick ascending limb
provides NaCl to increase the medullary osmolality and, at the
same time, to dilute the fluid in the lumen of the thick ascend-
ing limb. Osmolality continues to increase in the inner medulla,
but the mechanism for the concentrating effect remains contro-
versial. The most widely accepted mechanism remains the pas-
sive reabsorption of NaCl, in excess of solute secretion, from the
thin ascending limb (1,2), although the “passive mechanism”
hypothesis is not universally accepted.
Several studies showed that maximal urine-concentrating
ability is decreased in protein-deprived animals and humans
and is restored by urea infusion (3–10). These findings led to
the generally accepted concept that urea plays a critical role in
the urine-concentrating mechanism in the inner medulla. Two
urea transporter genes have been cloned: The UT-A (Scl14A2)
gene encodes six protein and nine cDNA isoforms; the UT-B
(Scl14A1) gene encodes a single isoform (reviewed in references
[11,12]). In recent years, several laboratories created mice in
which specific urea transporters were genetically knocked out
and used them to test long-standing hypotheses regarding
urea’s role in the urine-concentrating mechanism. In this issue
of the Journal of the American Society of Nephrology, Fenton and
Knepper provide a scholarly review of this important area of
investigation (13). As they discuss in their review, all urea
transporter knockout mice—UT-A1/UT-A3 (14,15), UT-A2
(16), and UT-B (17–19)— have urine-concentrating defects. The
urea transporter knockout mice support the concept that any
hypothesis regarding the mechanism by which the inner me-
dulla concentrates urine needs to include an effect that is de-
rived from urea and a role for urea transporters and, indeed,
seemingly support the architectural features of the passive
mechanism hypothesis.
As also discussed in their review (13), Fenton and Knepper
Published online ahead of print. Publication date available at www.jasn.org.
Address correspondence to: Dr. Jeff M. Sands, Emory University School of
Medicine, Renal Division, 1639 Pierce Drive, NE, Atlanta, GA 30322. Phone:
404-727-2525; Fax: 404-727-3425; E-mail: jsands@emory.edu
Copyright © 2007 by the American Society of Nephrology
used their UT-A1/UT-A3 knockout mice to test three classic
concepts regarding the role of urea in the concentrating mech-
anism: (1) The Berliner hypothesis that the role of urea trans-
porters in the inner medullary collecting duct is to prevent a
urea-induced osmotic diuresis (20), (2) the Gamble phenomena
that there is “an economy of water in renal function referable to
urea” (4), (3) and the passive mechanism hypothesis as pro-
posed by Kokko and Rector and by Stephenson (1,2). These
hypotheses are not mutually exclusive, so it is possible that they
all contribute to urinary concentration. Fenton and Knepper
interpret their findings (in their UT-A1/UT-A3 knockout mice)
to support the first two concepts (Berliner and Gamble) but not
the third (Kokko/Rector and Stephenson) (14,15,21).
In their review (13) but not in their original publications
(14,15), Fenton and Knepper conclude that the absence of the
inner medullary collecting duct urea transporters UT-A1 and
UT-A3 does not prevent the concentration of NaCl in the inner
medulla, contrary to what would be predicted from the passive
mechanism as proposed by Kokko and Rector and by Stephen-
son (1,2). Although authors generally have more poetic license
in reviews than in original manuscripts, some caution should
be exercised before reaching this conclusion that goes beyond
the original publication. Fenton and Knepper’s elegant studies
clearly show that inner medullary tissue urea content was
reduced markedly after water restriction in the UT-A1/UT-A3
knockout mice (14,15). They did not detect a measurable dif-
ference in NaCl content at two different levels of the inner
medulla between water-restricted UT-A1/UT-A3 knockout
mice and wild-type mice (14,15), which is inconsistent with the
predictions of the passive mechanism hypothesis (1,2) and the
basis for drawing their stronger conclusion in the review. How-
ever, the failure to detect a measurable difference in NaCl
content may have resulted from an unavoidable study design
limitation: The need to make measurements using the whole
papilla. NaCl concentrations progressively rise to their highest
values near the very tip of the papilla. It simply is not possible
to make thin enough sections of the papilla with enough tissue
to measure NaCl content, especially in a mouse. Therefore, the
averaging of tissue from the entire papilla may have masked
any increase at the papillary tip and prevented the detection of
a measurable difference in NaCl content in the water-restricted
UT-A1/UT-A3 knockout mice. If a decrease in NaCl content
had been detected in the UT-A1/UT-A3 knockout mice, then
that would have been very strong evidence in support of the
passive mechanism. However, the lack of supporting evidence
is not the same as evidence disproving the passive mechanism.
ISSN: 1046-6673/1803-0670
J Am Soc Nephrol 18: 670 – 671, 2007
Where does this leave us 35 yr after the initial publication of
the passive mechanism hypothesis (1,2)? It remains the most
widely accepted hypothesis to explain how the inner medulla
concentrates urine. There are experimental studies that support
it but also studies, including the UT-A1/UT-A3 knockout
mouse studies (14,15), that do not. Recently, Layton et al. (22)
proposed two hypotheses that are closely related to the passive
mechanism and were motivated by recent experimental find-
ings by Pannabecker et al. (23,24). Layton et al. performed
computer simulations for both hypotheses and found that the
predicted urine osmolalities were consistent with urine from
moderately antidiuretic rats. These simulations are a significant
advance because many earlier computer simulations had been
unable to generate comparably high urine osmolalities. Addi-
tional work, both experimental and theoretical, needs to be
performed to unravel fully the mystery of how the inner me-
dulla concentrates urine.
What impact do these findings have for the clinical nephrol-
ogist? Until another hypothesis is put forward to explain the
concentrating mechanism in the inner medulla, the passive
mechanism hypothesis remains a very useful model, both clin-
ically and for educating fellows, residents, and medical stu-
dents. As mentioned, any hypothesis regarding the mechanism
by which the inner medulla concentrates urine needs to include
an effect that is derived from urea, and the passive mechanism
hypothesis does so. It also provides an explanation for the
clinical observations in protein-deprived people. Last, as nicely
discussed by Fenton and Knepper, the demonstration that ge-
netic knockout of urea transporter proteins results in reduction
in urine-concentrating ability suggests that development of
agents that inhibit these transporters could be clinically useful
as novel diuretic or aquaretic agents.
Disclosures
None.
References
1. Kokko JP, Rector FC: Countercurrent multiplication sys-
tem without active transport in inner medulla. Kidney Int 2:
214 –223, 1972
2. Stephenson JL: Concentration of urine in a central core
model of the renal counterflow system. Kidney Int 2: 85–94,
1972
3. Pennell JP, Sanjana V, Frey NR, Jamison RL: The effect of
urea infusion on the urinary concentrating mechanism in
protein-depleted rats. J Clin Invest 55: 399 – 409, 1975
4. Gamble JL, McKhann CF, Butler AM, Tuthill E: An econ-
omy of water in renal function referable to urea. Am J
Physiol 109: 139 –154, 1934
5. Crawford JD, Doyle AP, Probst H: Service of urea in renal
water conservation. Am J Physiol 196: 545–548, 1959
6. Levinsky NG, Berliner RW: The role of urea in the urine
concentrating mechanism. J Clin Invest 38: 741–748, 1959
See the related article, “Urea and Renal Function in the 21st Century: Insights from Knockout Mice,” on pages 679 – 688.
Critical Role of Urea in the Urine-Concentrating Mechanism 671
7. Peil AE, Stolte H, Schmidt-Nielsen B: Uncoupling of glo-
merular and tubular regulations of urea excretion in rat.
Am J Physiol Renal Physiol 258: F1666 –F1674, 1990
8. Epstein FH, Kleeman CR, Pursel S, Hendrikx A: The effect
of feeding protein and urea on the renal concentrating
process. J Clin Invest 36: 635– 641, 1957
9. Klahr S, Alleyne GAO: Effects of chronic protein-calorie
malnutrition on the kidney. Kidney Int 3: 129 –141, 1973
10. Hendrikx A, Epstein FH: Effect of feeding protein and urea
on renal concentrating ability in the rat. Am J Physiol 195:
539 –542, 1958
11. Sands JM: Molecular approaches to urea transporters. J Am
Soc Nephrol 13: 2795–2806, 2002
12. Sands JM: Renal urea transporters. Curr Opin Nephrol Hy-
pertens 13: 525–532, 2004
13. Fenton RA, Knepper MA: Urea and renal function in the
21st century: Insights from knockout mice. J Am Soc Neph-
rol 18: 679 – 688, 2007
14. Fenton RA, Chou C-L, Stewart GS, Smith CP, Knepper
MA: Urinary concentrating defect in mice with selective
deletion of phloretin-sensitive urea transporters in the re-
nal collecting duct. Proc Natl Acad Sci U S A 101: 7469 –7474,
2004
15. Fenton RA, Flynn A, Shodeinde A, Smith CP, Schnermann
J, Knepper MA: Renal phenotype of UT-A urea transporter
knockout mice. J Am Soc Nephrol 16: 1583–1592, 2005
16. Uchida S, Sohara E, Rai T, Ikawa M, Okabe M, Sasaki S:
Impaired urea accumulation in the inner medulla of mice
lacking the urea transporter UT-A2. Mol Cell Biol 25: 7357–
7363, 2005
17. Yang B, Bankir L, Gillespie A, Epstein CJ, Verkman AS:
Urea-selective concentrating defect in transgenic mice lacking
urea transporter UT-B. J Biol Chem 277: 10633–10637, 2002
18. Yang B, Verkman AS: Analysis of double knockout mice
lacking aquaporin-1 and urea transporter UT-B. J Biol Chem
277: 36782–36786, 2002
19. Klein JD, Sands JM, Qian L, Wang X, Yang B: Upregulation
of urea transporter UT-A2 and water channels AQP2 and
AQP3 in mice lacking urea transporter UT-B. J Am Soc
Nephrol 15: 1161–1167, 2004
20. Berliner RW, Levinsky NG, Davidson DG, Eden M: Dilu-
tion and concentration of the urine and the action of anti-
diuretic hormone. Am J Med 24: 730 –744, 1958
21. Fenton RA, Chou CL, Sowersby H, Smith CP, Knepper
MA: Gamble’s “economy of water” revisited: Studies in
urea transporter knockout mice. Am J Physiol Renal Physiol
291: F148 –F154, 2006
22. Layton AT, Pannabecker TL, Dantzler WH, Layton HE:
Two modes for concentrating urine in rat inner medulla.
Am J Physiol Renal Physiol 287: F816 –F839, 2004
23. Pannabecker TL, Dantzler WH: Three-dimensional lateral
and vertical relationships of inner medullary loops of
Henle and collecting ducts. Am J Physiol Renal Physiol 287:
F767–F774, 2004
24. Pannabecker TL, Abbott DE, Dantzler WH: Three-dimen-
sional functional reconstruction of inner medullary thin limbs
of Henle’s loop. Am J Physiol Renal Physiol 286: F38 –F45, 2004