Bio342.

01 - Human Physiology - 2022/23-2

Lecture 13 - Kidney function and electrolyte balance

13.1 - Introduction

slide 2
Kidneys, despite their simple and relatively unstructured appearance (image on the right), are
multi-purpose organs that serve several important body functions. Besides the obvious
function, the removal of waste material from the body through urine production, kidneys play
important roles in homeostatic regulation. They regulate the volume of the extracellular fluid,
including the osmolarity and exact ion composition of body fluid. Extracellular fluid, i.e. the
fluid between cells of various tissues, is directly proportional to the blood volume, or better the
volume of blood plasma. Therefore, regulation of fluid volume has a direct consequence for
blood pressure and we will see that kidneys are intimately involved in blood pressure
regulation. This happens, in part inside the kidneys themselves but the kidneys also function
as important sensors for osmotic and fluid parameters and release hormones into the blood
stream that also affect blood pressure at various levels, ranging from constriction of blood
vessels and increasing cardiac output to triggering the release of ion-regulating hormones
from distant hormone glands, for instance the adrenal cortex. In addition, the kidneys, together
with the lungs, regulate the pH of body fluids, mainly blood plasma, and are, therefore, have
indispensible homeotic regulatory function.

13.2 - Anatomy of the urinary system

slides 3 / 4
Anatomically, the kidneys are part of the urinary (urine producing) system and realize most of
their homeotic function by changing the composition and / or amount of urine that they produce.
They are connected to the body by the blood circulation and to the outside through the urinary
bladder to release urine from the body. Kidneys are paired structure, i.e. one kidney on each
side of the body, that are connected through the ureters to the urinary bladder. The bladder
stores urine and releases it from the body through the urethra. The urinary system is located
at the level of the abdominal cavity underneath the diaphragm, which separates the thoracic
from the abdominal cavity. Technically, however, the urinary system is excluded from the
proper definition of the abdominal cavity because it is not surrounded by the membrane (the
peritoneum) that lines the inside of the abdominal cavity. Each kidney is supplied by a large
renal (rena = lat. kidney) artery and a vein. The adrenal gland is not part of the kidney structure
itself and is of different ontogenetic origin but it is situated on top of each kidney.

13.3 - Anatomy and histology of the kidney

slide 5
The kidney is surrounded on the outside by a thick and robust connective tissue membrane,
that forms the capsule and maintains the overall shape of the kidney. On the inside, two
distinct regions, the outer cortex and the inner medulla, can be distinguished. The medulla is
further segmented into pyramids that point towards the inner renal pelvis, an open space into
which urine is collected and which is connected to the ureter to transfer the urine to the bladder.
The functional unit of the kidney is the nephron (as we will see on the following slides), which
occupies both, the cortex and the medulla and the overall difference between those two
regions of the kidney is largely defined by the structure of nephrons, which are complicated
wound-up fluid-conducting vessels (called tubules) that are essential for all functions that the
kidney performs.

slide 6
The deep red appearance of the kidneys is due to the intense blood circulation through the
tissue. The renal artery branches of multiple times to form so called arcuate (= bow-shaped)
arteries that form loops inside the cortex and give rise to multiple afferent arterioles.
Remember that afferent referred to a conduit that brings something towards a tissue, e.g.
afferent neurons bring sensory information to the CNS. The afferent arterioles divide to form
tangles of capillaries, the renal glomeruli. Blood is removed from the kidney through the
arcuate veins and the renal vein, which connects directly to the vena cava inferior.

slides 7 / 8
The renal cortex is studded with blob-like structures, the renal corpuscles (= little bodies),
whereas the medulla is composed of multiple parallel tubes. The renal corpuscles contain the
glomeruli, which are surrounded by a single layer of cells that form the Bowman capsule. On
the inside, a fluid-filled space exists between the capsule and the glomerulus. Both, the cortex
and the medulla contain tubules but the orientation of these tubules is very different between
these regions. While tubules are largely (not exclusively) horizontal in the cortex, the tubules
are vertically oriented in the pyramids and point towards the renal pelvis.

13.4 - Anatomy of the nephron structure

slide 9
The nephrons are the major functional units of the kidney and the overall structure of the
kidney is formed by the repetition of hundreds of thousands of nephrons. The nephron is a
convoluted structure that is composed of the tubules formed by the nephron itself and
surrounding blood capillaries. It begins at the Bowman capsule (renal corpuscles) from which
a largely horizontally oriented proximal (close to something) tubule emerges. This tube makes
a strong bend, the descending limb, which extends into the medulla part of the kidney. Here it
forms a loop, the loop of Henle, and climbs back up to the cortex at the ascending limb to give
rise to another horizontal segment, the distal (far away from something) tubule. Multiple
nephrons join one of several common collecting ducts that empty their content into the renal
pelvis. Generally, fluid is generated inside the Bowman capsule and runs through the tubular
system down and back up from the cortex to the medulla and then again down the medulla to
the pelvis.

slides 10 / 11
There are two morphologically distinct types of nephrons, those that form a loop of Henle close
to the upper parts of the medulla and those that form a loop deeper inside the medulla
structure. Those, that bend backwards in the upper medulla are more common (about 80% of
all nephrons) and are called cortical nephrons. Those that dive deeper into the medulla are
called juxtamedullary nephrons. Each nephron is surrounded by a bed of capillaries, the
peritubular capillaries, which follow the tubular structure into the medulla. Peritubular
capillaries of cortical nephrons are connected in a web-like fashion, whereas the capillaries of
juxtamedullary nephrons run largely straight alongside the descending and ascending limbs
of the tubule structure. Peritubular capillaries originate from the blood vessels that leave the
Bowman capsule and which are called the efferent arterioles.

slides 12 / 13
Glomeruli inside the Bowman capsule are formed by a mass of capillaries at which blood
plasma is filtered through fenestrations in endothelial cells. Remember that we briefly
discussed the different types of capillaries. Fenestrated capillaries are capillaries that contain
pores that extend through the endothelial wall and which allow the fluid compartment of the
blood and some of the smaller dissolved ions and organic materials to leave the lumen of
blood vessels.

slide 14
The glomerular capillaries are surrounded by podocytes that contribute to the formation of
filtration slits and which act as a sieve to retain larger material inside the capillaries. The fluid
is filtered into an open lumen between the capillaries and the capsule, which is directly
connected to the proximal tubule. The afferent arteriole brings blood into the glomerulus
structure and the remainder of the blood that has not been filtered out into the lumen of the
Bowman capsule leaves the renal corpuscle through the efferent arteriole to form the
peritubular capillaries. The ascending limb of the tubular structure is actually bend in a way
that it passes through the junction between the afferent and efferent arteriole to form an
important regulatory unit, the juxtaglomerular apparatus (see later).

slides 15 / 16
Podocytes are fascinating cells that form tooth-like processes that interdigitate around blood
vessels . The spaces between the “teeth” act as filtration slits together with the pores in the
endothelial wall. Filtered material has to pass these slits and the basal lamina between the
endothelial cells and the podocytes. As a consequence, only the liquid plasma and dissolved
material, but not larger cells, are leaving the capillaries into the lumen of the Bowman capsule.

13.5 - Fluid handling and glomerular filtration rate

slide 17
Each day, we produce about 1.5 liters of urine. However, this is only at the overall level after
several processing steps that take place within the kidneys. The amount of primary filtrate that
is produces is much higher (more than 100 times) than the amount of urine that is finally
produced. Filtration at the level of all glomeruli of both kidneys combined amounts to a
stunning 180 liters per day. This is largely because of the unrestrained filtration through
fenestrated capillaries. The human body holds about 5 liters of blood, 3 liters of which are fluid
plasma. Thus, the entire fluid compartment of the plasma is filtered 60 times a day at the level
of glomeruli, or in other words, your entire plasma volume gets filtered every 24 minutes. This,
of course, is not compatible with life and most of the filtered plasma needs to be regained
through various steps that take place later in the tubule structure of the nephron. Most
reabsorption of the filtered fluid occurs in the proximal tubule and only 54 liters of filtrate are
left after passage through the proximal section. An important side aspect of filtration in the
Bowman capsule and reabsorption in the proximal tubule is that the process is isosmotic. The
primary filtrate has the same composition and osmolarity as the blood plasma of 300 mOsm,
which is primarily based on sodium, urea, and glucose. The filtrate that leaves the proximal
tubule also has the same osmolarity of 300 mOsm, suggesting that reabsorption of fluid in the
proximal tubule is isosmotic. Things, however, change dramatically in the later sections of the
tubule structure. Reabsorption also occurs in the descending and ascending limbs of the
Henle loop but the remaining filtrate of 18 l that reaches the distal tubule has a lower osmolarity
of about 100 mOsm, indicating that more osmotically active solutes were reabsorbed than
water. The main reason for this is the osmotic environment in the renal medulla, which
changes with increasing distance from the cortex, as we will see later. The largest change in
osmolarity, however, occurs in the collecting duct and the composition of the final urine has a
wide range of osmolarity that it can adopt, which ranges between 50 to 1.200 mOsm. How
osmotic the final urine will be depends on a multitude of different conditions, such as fluid
volume in the body or whether solutes have to be removed or retained as a consequence of
homeostatic regulation.

slides 18 / 19 / 20
Both, the fluid volume and its osmotic composition are controlled by three processes, filtration,
absorption, and secretion. The amount of fluid and volume that is removed from the body then
constitutes the excreted fraction and is a consequence of the balance between the three
mechanisms mentioned above. While filtration only occurs at glomeruli, reabsorption takes
place by exchange between the tubule lumen and the lumen of the peritubular capillaries.
Likewise, secretion occurs in the opposite direction between peritubular capillaries and the
tubular nephron. The different sections of the nephron are involved with different transport
mechanisms and transport in different directions. Filtration takes place only in the Bowman
capsule, while secretion (the removal of extra solute material by an active transport
mechanism) occurs in the proximal and distal nephron and within the collecting duct. All
sections are capable of reabsorption and the descending and ascending nephron only
reabsorb without being able to secrete any solutes.

slide 21
In the chapter on blood vessel structure, when we first looked into the phenomenon of filtration
at capillaries, we identified the blood pressure and the colloid osmotic pressure of the blood
plasma as the major driving forces for the balance between filtration and reabsorption. In
principle, the same forces are at work inside the Bowman capsule but because the capsule
and the tubules are a closed system, any filtered fluid also increases the hydrostatic pressure
inside the nephron. This is different from loose tissue, where the filtered fluid would dissipate
between cells. Thus, in the Bowman capsule the fluid pressure of the filtrate opposes further
filtration, resulting in a relatively low net filtration pressure.

slide 22
Thus, blood pressure is the major drive that determines filtration in glomeruli. The expectation
would be that an overall increase in mean arterial blood pressure would result in increased
fluid filtration and eventually more urine production. The opposite should be true if the blood
pressure is low in the somatic circulation. Yet, the glomerular filtration rate (GFR) of 180 liters
per day is relatively constant over a relatively wide range of blood pressures between 80 and
180 mm Hg. Only at very low and very high blood pressure is filtration rate affected. This is
why prolonged low blood pressure can result in kidney failure because less than required
filtrate is formed. Therefore, an important question is, how GFR remains so stable with
changing blood pressure.

slide 23
An important contribution to regulation of GFR comes from the constriction and dilation of the
blood vessels that bring blood to or remove it from the glomerular capillaries. Vasoconstriction
of the afferent arteriole decreases the blood pressure behind the constriction, thus, blood
pressure and, therefore, filtration pressure are decreased and GFR will be reduced. The
opposite is true for constrictions of the efferent arteriole. Constriction of this blood vessel
would result in an increase in blood and filtration pressure ahead of the constriction, thus,
within the glomerulus.

slide 24
Two different mechanisms contribute to autoregulation of GFR, which include a myogenic (=
smooth muscle) response in the afferent arteriole and the more complicated process of
tubuloglomerular feedback. During the myogenic response, increased stretch of the afferent
arteriole due to increased blood pressure results in constriction of the blood vessel. The
consequence is reduced blood flow into the glomerulus and reduced filtration pressure as
explained on the previous slide.

slides 25 / 26 / 27
Tubuloglomerular feedback describes a much more complex form of regulation but, ultimately,
also results in constriction or dilation of the afferent arteriole to regulate filtration pressure.
First, the overall structure of the nephron is not as unfolded as shown on previous slides.
Rather the ascending limb of the Henle loop passes through the junction of the afferent and
efferent arteriole at the back of the glomeruli. This configuration is called the juxtaglomerular
apparatus. Specific cells in the wall of the ascending limb, the macula densa cells, can sense
the composition of the filtrate passing through them. If filtration exceeds reabsorption the
composition changes, which is sensed by the macula cells, which in turn secrete a paracrine
that changes the diameter of the afferent arteriole. We are only beginning to understand what
macula cells really can detect. An important parameter appears to be the concentration of
sodium ions but these cells also express chemosensory receptors, including smell receptors
normally found in the nose, to analyze the composition of the filtrate. Slide 26 shows a stunning
histological image of the configuration of the juxtaglomerular apparatus. Slide 27 summarizes
the process step by step.

slide 28
A question that arises from what we have seen so far might be, why GFR is so high. The
problem of urine production could be solved much more economically by producing only the
amount of urine that is adequate for any given electrolyte and water condition of the body.
Both reabsorption and secretion depend on specific transport mechanisms across the wall of
the tubules and the glomerular capillaries. To be able to remove specific material from the
body, very specific transport molecules would needed to be incorporated into these walls but
many times the nature of the foreign material to be excreted is not known and a specific
transporter does not exist. As a consequence, certain solutes would accumulate in the blood
if they cannot be transported out of blood vessels. Filtration in the Bowman capsule is blind,
essentially everything except proteins and cells, is filtered and material that is necessary for
body function is reabsorbed. Different from secretion, it can be known by the body which
substances are required and should be absorbed. Nevertheless, some solutes are actively
transported out and removed with the urine, but specific transporters exist for these
substances to increase the efficiency of their removal.

13.6 - Transport mechanisms

slide 29
Transport across the tubule or blood vessel wall can take two routes, either across the
junctions between two neighboring cells or across the two membranes of the cell on the apical
and basolateral side.

slide 30
Transport in kidney tubules uses both transport mechanisms but they occur for different
materials. Water and some anions can be transported through the paracellular pathway driven
by osmotic gradients, while most other solutes have to be actively transported across cells.
This often involves specific but different transport molecules in the apical and basolateral
membrane. The two mechanism often work together, as for instance during isosmotic
reabsorption in the proximal tubule. Solutes (Na+, K+, Ca2+, glucose, and urea) are transported
across cells on specific membrane transporters. Water follows through a paracellular pathway
because the moved ions build up an osmotic gradient. The same is true for some negatively
charged ions because most of the solutes transported actively are positively charged.

slide 31
One example of reabsorption in the proximal tubule is the transport of sodium, which drives
most of the other transport phenomena. The concentration of sodium ions in the filtrate inside
the tubule lumen is relatively high, at least higher than within cells of the tubule wall. Sodium
is moved out of the cells at the basolateral membrane by the ubiquitous ATP-driven sodium-
potassium pump, which lowers the intracellular Na+ concentration. Therefore, sodium ions can
enter the cell by facilitated diffusion on the apical membrane because of the concentration
difference that is generated by the Na+/K+ pump.

slide 32
The transport of other solutes, for instance glucose, is coupled to the transport of sodium.
Glucose can enter the tubule cells on the apical membrane through a sodium-glucose
transporter (SGLT symporter) because of the sodium concentration difference between the
tubule lumen and the cytoplasm. Glucose then leaves at the basolateral membrane through
GLUT transporters, which facilitate membrane transport of glucose down its concentration
gradient.

slides 33, 34, 35

The glucose example nicely illustrates how important the presence of specific transporters is
for kidney function. Glucose, like most dissolved solutes is freely filtered at glomerular
capillaries. Therefore, the filtration rate of glucose is a simple linear reflection of the plasma
glucose concentration. If there is more glucose in the plasma, more glucose if filtered at
glomeruli (slide 33). However, the number of glucose transporters is limited in the tubule wall
and above a certain threshold, no additional glucose molecules can be reabsorbed by the
kidney. This state is called the transport maximum for glucose (slide 34). As soon as the
transport maximum is reached, some glucose molecules remain in the filtrate that cannot be
reabsorbed (= renal threshold; slide 35). This is not normally seen for physiological
concentrations of plasma glucose and typically no glucose is found in the urine. This, however,
changes under certain metabolic disorders, such as diabetes, when nutrition-derived glucose
cannot be taken up by cells. Thus, a hallmark of diabetes is the presence of glucose in the
urine because the transport maximum of glucose transporters in the proximal tubule is
exceeded.

13.7 - Renal clearance

slide 36
We already mentioned that excretion, the removal of a substance from the body through urine,
is the result of filtration, reabsorption, and active secretion. A common parameter in a clinical
setting is to reformulate this into the concept of clearance, which measures the rate at which
a substance disappears from the body. Clearance, also depends on the balance between
secretion and reabsorption but allows us also to understand their selective contribution to
excretion. As we will see, it also allows us to obtain an estimate of GFR.

slide 37 / 38
Let's look first at an easy example. Inulin is a xenobiotic, a substance that is not produced by
the body and has no essential function but is sometimes found in certain plant-based foods.
The GFR of 180 l per day is approximately equivalent to 100 ml / min (actually it is 125 ml /
min). If the plasma contains inulin at a certain concentration, in this example 4 molecules per
100 ml, then 4 molecules of inulin are filtered per minute with the 100 ml of plasma. Because
inulin is neither reabsorbed or secreted along the nephron, all 4 molecules end up in the urine,
while 99% of the plasma will be reabsorbed along its passage through the nephron. Clearance
now measures the volume of plasma that has been cleared of a solute per interval time. In
this case, 100 ml of plasma are cleared of inulin per minute. This is a very derived but useful
measure in medicine.

slide 39
A naturally derived molecule that is only filtered but not reabsorbed or secreted is creatinine.
We have seen in the chapter on muscle physiology that phospho-creatinine is an energy
storage molecule in skeletal muscle cells. The comparison of urine and plasma concentration
of creatinine allows us to estimate GFR. Let's assume that a 24h urine sample (i.e. all the
urine produced over a 24 period) contains 1.860 mg of creatinine, which is equivalent to an
occurrence of creatinine in the urine at a rate of 1.3 mg / min (1.860 mg / 1.440 min (= 24 h x
60 min)). The concentration of creatinine in the blood is much lower at only about 0.01 mg /
ml. Because, like inulin, creatinine is neither reabsorbed nor secreted, the 1.3 mg creatinine
that occur in the urine every minute amount to a plasma volume of 130 ml. Thus every minute
130 ml of plasma are cleared of creatinine. Over 24 h this amounts to 186 l of plasma that are
cleared and, in this case, it is equivalent to GFR.

slide 40
Glucose, as we have seen, is handled differently by the kidney. Under normal conditions all
of the filtered glucose is reabsorbed by the nephron, thus glucose clearance does not occur
(clearance rate: 0 ml of plasma / min).
slides 41 / 42
Urea, a breakdown product of amino acids (urea cycle) is both filtered and partially reabsorbed.
Therefore, clearance is lower than for creatinine but higher than for glucose. On the other
hand the antibiotic penicillin is both filtered and secreted, and, therefore, is higher than GFR.
Maybe now you can understand why clearance is a relevant parameter in medicine because
it describes the handling of a foreign substance, e.g. a useful drug, by the kidney. Because
penicillin is cleared so efficiently, you usually need to take a high dose and multiple doses a
day for it to stay physiologically active in fighting bacterial infections.

13.8 - Kidney stones

slides 43 - 46
Urea is a breakdown product of amino acid metabolism and has several important functions
in the kidney besides being reabsorbed. It is the major osmotically active substance in the
renal medulla, which is important for water and ion reabsorption. Uric acid ( a different
molecule with a similar sounding name) is a breakdown product of purine metabolism and can
create certain problematic symptoms if the concentration is too high. Uric acid easily forms
urate crystals, which cause inflammation at joints in a condition called gout (tr: gut). The
formation of crystals can also occur inside the urinary system (kidney and urinary bladder)
because one of the functions of the kidney is to concentrate material that should be removed
from the body. Uric acid precipitations in the kidney are referred to as kidney stones. Certain
foods trigger gout attacks and are also at the heart of kidney stones, in particular foods that
are rich in purines, such as seafood and internal organs.

slide 47
The handling of uric acid by the kidney is complex and includes filtration, secretion and
reabsorption at high levels. About 90 % of uric acid is reabsorbed despite the high secretion
rate of 50%.

13.9 - Water and electrolyte regulation by the kidney

slide 48
One important function of the kidney is to regulate water balance in conjunction with the
osmolarity of the extracellular fluid. About 50 to 60% of the human body are composed of
water, depending on gender and lifestyle. This amounts to about 42 liters in the standard 70
kg male. Of those about 2/3 are found inside cells (cytoplasm) and1/3 in the spaces between
cells (interstitial fluid). As we mentioned many times over, another 3 liters is circulating with
your blood stream. The homeostasis of water levels inside your body is the balance between
water uptake and water loss. Sources of water gain are food and drink, which amounts to an
average of 2.2 liters/day. In addition, metabolic breakdown of glucose during oxidative energy
production also generates about a cup (0.3 l) full of water every day. Your body looses water
with the urine but besides this obvious loss, there is also an insensible loss of water by
evaporation through the skin, from the lung and with the feces. Insensible water loss is actually
quite high and reaches close to a liter per day in a regular person. Of these, only water intake
through drinking can be controlled behaviorally and at the level of physiology, urine production
is the most critical regulated variable. Excess of body fluid would result in the production of
large amounts of dilute (low osmolarity) urine, while water deficits would result in the
production of small amounts of high osmolarity urine.

slide 49
Urine production is directly linked to blood pressure, not only at the level of filtration. Although,
we have already seen that filtration rate is fairly constant over a wide range of blood pressure.
Low blood pressure, as a sign of water deficit in the body, increases cardiac output and
vasoconstriction through sympathetic activation. At the behavioral level, it also triggers thirst,
mostly through the sensation of an increase in body fluid osmolarity. Important for our topic,
the kidney would also be instructed to conserve water and to produce smaller amounts of
urine than under normal body hydration or blood pressure. Elevated blood pressure is
regulated by the kidney through the excretion of salts and water to reduce the volume of
extracellular and intracellular fluid and plasma. It is important to regulate both water and
solutes to prevent water retention by osmotic activity.

slide 50
Let’s follow one more time the flow of fluid through the nephron structure. Remember that we
have different types of nephrons (cortical and juxtamedullary) that extend to different strata in
the medulla. Ion and urea absorption in the parts of the nephron that extend into the medulla
generate an osmotic gradient in the extracellular fluid of the medulla tissue. This gradient is
largely set up by the activity of juxtamedullary nephrons and the vasa recta, the specialized
peritubular capillaries of these nephrons. The osmolarity gradient reaches a maximum of
about 1.200 mOsm at the innermost regions of the medulla. In contrast, the osmolarity in the
cortex is isosmotic to plasma at about 300 mOsm. Thus filtrate that enters the descending
duct of the Henle loop will be exposed to increasingly high osmotic environments. This drives
water out of the tubule into the surrounding medullary tissue. Thus, at the tip of the loop of
Henle the osmolarity of the filtrate also reaches the same high osmolarity of 1.200 mOsm. As
the filtrate moves upwards again through the ascending limb, it is exposed to less and less
osmotic conditions. In this section of the nephron, only ions can be reabsorbed but not water,
whereas the descending limb is only permeable to water but not ions. Because salt
reabsorption is also driven by active pumps that consume ATP and not only by osmotic
balance, the osmolarity of the filtrate that enters the distal tubule in the renal cortex has a
slightly lower osmolarity (50 – 100 mOsm) than the surrounding tissue. This fluid then enters
the collecting duct, which again passes through the high osmolarity environment of the
medulla. It is in the collecting duct, where water reabsorption is regulated, and this regulation
adjusts the amount urine that is excreted as well as the osmotic composition of the urine.

slide 51
As already mentioned, about 80% of nephrons are cortical, that is, they do not reach deep into
the medulla. It is actually the juxtamedullary nephrons that establish the osmotic gradient that
can be used as a driving force to move ions or water from the tubule lumen into the kidney
tissue. The high osmolarity deep inside the medulla is also used as an osmotic driving force
in the collecting duct as we will see later.

slides 52 - 61
The following sequence of slides is a stepwise explanation of the establishment of the osmotic
gradient by juxtamedullary nephrons together with the vasa recta.
slide 52: Imagine a hypothetical timepoint early in development before the nephrons are active.
The kidney tissue will have the same osmolarity as other tissues and the blood plasma,
which is around 300 mOsm.
slide 53: The ascending limb is largely only permeable to ions because of the presence of
specific NKCC (sodium, chloride, potassium transporters) but not to water.
slide 54: Movement of ions out of the ascending limb by ion transporters increases the
osmolarity of the surrounding tissue. As they pump out more and more ions, the
osmolarity inside the ascending limb decreases as the fluid moves back towards the
cortex, where it reaches about 100 mOsm.
slide 55: In contrast to the ascending limb, the descending limb is only permeable to water.
slide 56: Thus, the osmolarity of the fluid inside the tubule will also increase as it travels
downwards within the medulla.
slide 56: Because the osmolarity inside the tubule reaches its highest value near the loops of
Henle, the NKCC transporters at the beginning of the ascending limb transport more
ions to the outside than transporters that are located higher up in the ascending limb.
As they pump out more and more ions, the osmolarity inside the ascending limb
decreases as the fluid moves back towards the cortex.
slide 57: Over time, this process established a gradient from low to high osmolarity along the
cortex to medulla axis.
slide 58: And because the descending limb is permeable to water, the same gradient is
established inside the tubule lumen.
slide 59: The water that moves out of the tubule would ultimately dilute the osmolarity in the
medulla again and break down the gradient. However, the vasa recta can take up ions
and water as they extend through the same osmolarity differences. They essentially
pick up the ions and the water that comes out of the ascending and descending limb,
respectively. This arrangement is called a countercurrent configuration.
slide 60: The collecting ducts also pass through the same gradient and now the gradient is the
“motor” to drive the regulated movement of water out of the collecting duct. We will see
later how the water reabsorption is regulated here through the action of a hormone
that is called arginine-vasopressin (AVP).

slide 61
This slide shows again the relationship between the nephron tubules and the vasa recta. If
water and ions would only move out of the tubule lumen and would remain in the extracellular
fluid of the renal medulla, the concentration gradient would not be stable over time and break
down pretty quickly. Therefore, both water and ions are reabsorbed by the vasa recta to
stabilize the gradient in the form of a countercurrent amplifier. The osmolarity of the blood is
isosmotic at all levels to the surrounding tissue. Thus, peritubular capillaries reabsorb water
and ions in an isosmotic process. Low osmolarity blood that is transported downwards in the
medulla picks up ions from the high osmolarity environment and hyperosmotic blood that
moves upwards in the medulla is diluted by water.

slide 62
The final composition (osmolarity and volume) of the urine is decided in the collecting duct as
the filtrate passes through the medulla before entering the renal pelvis. The cells that form the
collecting duct have regulated water permeability. Thus, if they are fully permeable, the urine
osmolarity will also reach 1.200 mOsm at the end of the collecting duct. However, if the
collecting duct is sealed and completely impermeable to water, the osmolarity of the urine
would be identical to its osmolarity in the distal tubule, about 100 mOsm.

slides 63 / 64
The signal that regulates the permeability of the collecting duct is the hormone vasopressin
that is released from the posterior pituitary.

slide 65
Vasopressin binds to membrane receptors that trigger the fusion of membrane vesicles with
the apical membrane of the collecting duct cells that faces the lumen of the duct. These
vesicles contain the water channel aquaporin. Thus, the apical membrane of these cells is
water impermeable unless some of these water channels are inserted into their apical
membrane. Water permeability on the basolateral membrane is not regulated. If vasopressin
concentrations are low, membrane endocytosis removes more aquaporin channels from the
membrane than channels that are integrated into the membrane through exocytosis.
Vasopressin, better arginine vasopressin, is also called antidiuretic hormone to reflect its
action in the collecting duct where it prevents diuresis, the production of urine.

slides 66 / 67
Different stimuli trigger the release of vasopressin. These triggers include 1) increased
extracellular fluid osmolarity that is sensed by hypothalamic osmoreceptors, 2) decreased
atrial stretch because of low blood pressure, and 3) decreased blood pressure sensed by
carotid and aortic baroreceptors. The sensation by hypothalamic neurons is interesting
because it requires that plasma osmolarity is also reflected by osmolarity of the cerebrospinal
fluid in the brain despite the blood brain barrier. Plasma vasopressin concentrations are low
but fairly linear over a physiologically meaningful range between 280 and 300 mOsM.

slide 68
The kidney not only regulates water balance but also ion concentration of the extracellular
fluid. Salt reabsorption occurs in the proximal tubule, the ascending limb, and the distal
nephron. Of those, ion reabsorption is only regulated in the distal tubule, while it is largely (but
not exclusively) controlled by osmotic activity. Solute transport in the proximal nephron is
isosmotic, while in the Henle loop water and ions also follow their osmotic gradient. In addition,
transport is in the ascending limb is powered by the ATP-driven sodium-potassium pump on
the basolateral membrane. These cells lack water channels and therefore only ions can cross
the tubule wall. When the fluid inside the tubule moves from regions of high to low osmolarity,
ions are reabsorbed by entering the cell through NKCC (sodium-potassium-chloride)
symporters on the apical membrane and through chloride and potassium channels on the
basolateral membrane in addition to potassium-chloride symporters

slide 69
Ingestion of salt (e.g. potato chips, popcorn, other tasty junk food) results in changes in
extracellular fluid osmolarity largely without changes in volume. This triggers the release of
vasopressin from the posterior pituitary to reabsorb additional water to dilute the ion
concentration in the ECF. It also triggers behavioral mechanisms (drinking) through the feeling
of thirst, which also adds additional volume to the ECF. Because ECF volume and osmolarity
are directly linked to plasma volume, they are important homeostatic control parameters to
regulate blood pressure.

slide 70
An important hormone that regulates Na+ ions is aldosterone, which is produced by the adrenal
cortex, the hormone producing gland surrounding the modified sympathetic ganglion on the
inside of the gland. Aldosterone is classified as a mineralocorticoid because of its effect on
ion reabsorption by the kidney. It promotes sodium uptake in exchange for potassium.
Aldosterone release from the adrenal cortex can be stimulated by elevated levels of potassium,
which makes sense because potassium and sodium are normally transported in opposite
directions across membranes. Thus high potassium indirectly signals low sodium or ion
imbalance in general. Because aldosterone triggers the uptake of sodium ions its release is
also inhibited by very high levels of osmolarity because under this condition, ion uptake would
increase hyperosmolarity, which would be detrimental to body function. A second route of
aldosterone regulation is through blood pressure and aldosterone release is triggered by low
blood pressure through a complicated pathway, the renin-angiotensin-aldosterone pathway or
RAS system (for renin-angiotensin system).

slide 71
At the level of the distal nephron, aldosterone triggers the synthesis of additional channels
and pumps (and modifies the activity of existing proteins) to increase the transport efficiency
in P cells. As a net result, potassium is excreted into the tubule lumen and sodium is
reabsorbed into the plasma.

slides 72 / 73
As a short summary, aldosterone released from the adrenal cortex affects Na+ reabsorption
by the distal nephron tubule to increase plasma (and ECF) volume and to maintain osmolarity.
The RAS pathway is executed in response to low blood pressure and starts with the synthesis
of an inactive precursor, called angiotensinogen from the liver. Angiotensinogen is cleaved by
the hormone renin that is released from granular cells the kidney in response to low blood
pressure. We will see on the next slide the different parameters that regulate renin release.
The activated angiotensin I is further converted by an angiotensin-converting enzyme (ACE,
the molecular receptor of the Corona virus) produced largely by the lung and upper airway
tissues into the effector angiotensin II. Angiotensin II has many effects that all work together
to increase blood pressure (e.g. vasoconstriction, increasing cardiac output) but also triggers
the release of vasopressin and aldosterone. The result is increased absorption of sodium and
water by the kidney.

slide 74
The regulation of renin release by granular cells in the kidney is complex and multiple stimuli
converge onto these cells. Granular cells are specialized cells in the wall of the afferent
arteriole. We have seen that the afferent arteriole is stretch sensitive. Low stretch during low
blood pressure directly triggers renin secretion. In addition, low GFR measured as a decrease
in NaCl transport into macula densa cells also triggers renin secretion through a paracrine.
This paracrine, however is different from the paracrine that regulates constriction of the
afferent arteriole during tubuloglomerular feedback. Sympathetic activity, which increases as
a consequence of activating baroreceptor reflexes also contributes to stimulation of renin
release. Thus, three different stimuli, which all signal low blood pressure result in renin
production.

slide 75
The same regulators but stimulated by additional hormones are involved in responses to high
blood pressure. High blood pressure results in increased stretch in the atria and myocardium
(heart muscle wall), which release natriuretic peptides. As the name describes (natri à sodium,
uretic à in urine), these peptides have the opposite effect from aldosterone and result in
sodium excretion. Natriuretic peptides decrease vasopressin release form the pituitary,
increase GFR and therefore decrease renin release, and prevent the release of aldosterone
from the adrenal cortex. The combined result of these activities is excretion of NaCl and water
by stopping sodium reuptake in the proximal tubule and water reabsorption in the collecting
duct.

slides 76- 81
These slides, in a stepwise fashion, combine all the knowledge that we have now about the
regulation of body fluid and osmolarity. It is too complicated to describe this here but the slides
first review the different systems: cardiovascular responses, hypothalamic responses, the
RAS pathway, and the kidney mechanism, and then connect them to each other. Please take
some time to follow the flow of signals and cross-effects.

13.10 - pH regulation

slide 82
Another important function of the kidney is the regulation of body pH. Normally the body pH is
adjusted within a very narrow range between 7.38 and 7.42 since both low and high
disturbances have profound effect on cell function. High acidity may lead to denaturation of
proteins and concomitant loss of their function or efficiency. In the nervous system acidosis (=
low pH) results in reduced excitability of neurons, while alkalosis (high pH) makes neurons
hyper-excitable. This in turn has secondary effects not only on cognitive brain function but
also on regulatory pathways that control organ function and feedback loops. The main reason
for the link between nerve cell excitability has to do with the fact that pH regulation by the
kidney is linked to potassium transport and that changes in extracellular potassium
concentration changes the resting potential of nerve cells.

slides 83 / 84 / 85
Typically, pH disturbances caused by acids are more common reflecting the presence of acids
in many food items (e.g. lemon juice, fruits) and that few foods have a basic pH. In addition,
fatty acids and amino acids from the diet contribute to low pH in addition to metabolically
derived protons. The stability of body pH is largely due to large buffer reservoirs in the body,
extracellular fluid and plasma contains vast amounts of bicarbonate but also proteins and
other organic molecules can buffer protons. Two organs contribute to pH regulation, the lung
and the kidney. Protons are removed through the lung by their conversion into carbon dioxide
as discussed in the chapter on respiration in a fast response. The kidney, albeit with a slower
response time, is able to transport free protons into the urine.
Slide 86
Two distinct sections of the nephron contribute to pH regulation, the proximal tubule and the
collecting duct. In the proximal tubule protons are largely excreted in several complicated
pathways that result in bicarbonate absorption and proton removal. The primary filtrate
contains a lot of bicarbonate that is worth being reabsorbed. Proximal tubule cells secrete
protons in exchange for sodium, which combines with filtered bicarbonate to form carbon
dioxide (carboanhydrase reaction). The gas diffuses into cells, where it is hydrolytically split
again into bicarbonate, which is absorbed through a sodium-bicarbonate transporter, and a
proton, which is again secreted. The result is net absorption of bicarbonate. The tubule cells
also remove protons that are bound to amino acids as shown for the glutamine example, which
is metabolized into ammonium and through several steps into bicarbonate. The ammonium
and attached proton is secreted into the tubule lumen.

slide 87
In the collecting duct two different cell types, type A and B cells, are involved in proton
regulation. These cells are mirror images of each other with respect to the distribution of
membrane transporters in their apical versus basolateral membranes. Type A cells function in
acidosis and actively pump protons into the tubule lumen. One route is through a potassium-
proton antiporter, thus proton secretion goes along with potassium reabsorption. Type B cells
do the opposite, they absorb protons and secrete bicarbonate and function under alkalosis.

- End of transcript (shf, 11.05.2023)