Nephrology Module

Biochemistry

The molecular basis of

renal transport systems
Weekly Learning Objective(s):

• Review the general mechanisms of solute and water transport

across the nephron

• Describe the different characteristics of the following renal

transporters: transport ATPases, ion and water channels, coupled
transporters

• List the nephron sites and understand the molecular mechanisms of

action of various classes of diuretics

• Name clinical syndromes related to defects in specific renal

transporters (e.g., Bartter’s, Gittelman’s, Liddle’s, etc.)
Introduction
Transport systems
Limits to rate of transport
Hormonal regulation of transport rate
Diuretics
Disorders in transport system
• The maintenance of a relatively constant volume and a stable
composition of the body fluids is essential for homeostasis

• Some of the most common and important problems in clinical

medicine arise because of abnormalities in the control systems
that maintain this relative constancy of the body fluids

Daily water intake and output (ml)

• the most important means by which the
body maintains fluid homeostasis is
adjustment of the rates at which the
kidneys excrete water and electrolytes Urine 1400

• For example, urine volume can be as low as 0.5 L/day in a

dehydrated person or as high as 20 L/day in a person who has
been drinking tremendous amounts of water

• This variability is also true for most of the electrolytes of the

body, such as sodium, chloride, and potassium
• The total body fluid is
distributed between
extracellular fluid
(interstitial, plasma,
lymph, transcellular), and
intracellular fluid

• the capillary membranes

are highly permeable to
water and solutes

• Cell membranes are

permeable to water but
not to electrolytes
• the E fluid contains large
amounts of sodium and
chloride, reasonably large
amounts of bicarbonate, but only
small quantities of potassium,
calcium, magnesium, phosphate,
and organic acid ions.

• the I fluid contains only small

quantities of sodium and
chloride and almost no calcium:
instead, it contains large
amounts of potassium and
phosphate, moderate
magnesium and sulfate
• About 80 % of the total osmolarity
of the interstitial fluid and plasma is Na+ 142 139
K+ 4.2 4.0 140
due to sodium and chloride ions
Cl- 106 108

• For intracellular fluid, almost half

the osmolarity is due to potassium
ions and the remainder is divided
among many other substances

• Large osmotic pressures can

develop across the cell membrane
with relatively small changes in the
concentrations of solutes in the
extracellular fluid
Cortex

Medulla
Ø Nephron of the kidneys:

The labelled parts are 1.

Glomerulus, 2. Efferent arteriole,
3. Bowman's capsule, 4. Proximal
convoluted tubule, 5. Cortical
collecting duct, 6. Distal
convoluted tubule, 7. Loop of
Henle, 8. Papillary duct, 9.
Peritubular capillaries, 10.
Arcuate vein, 11. Arcuate artery,
12. Afferent arteriole, 13.
Juxtaglomerular apparatus
Urine results from the net effect
of three different processes:

Glomerular filtration - tubular

reabsorption + tubular secretion

• Filtration: nonselective

• Reabsorption: highly
selective
• As the glomerular filtrate enters
the renal tubules, it flows
sequentially through the
successive parts of the tubule

• Along this course, substances

are selectively:

• reabsorbed from the

tubules into the blood, or
• secreted from the blood
into the tubular lumen

• Excretion as urine
• The renal circulation is unique in
having two capillary beds, the
glomerular and peritubular capillaries,
separated by the efferent arterioles

• High hydrostatic pressure in the glomerular capillaries: rapid

filtration

• Lower pressure in the peritubular capillaries: rapid fluid

reabsorption

• By adjusting the resistance of the afferent and efferent arterioles,

the kidneys regulate the hydrostatic pressure in both capillaries
beds to achieve homeostasis
• The GFR is about 20% of RPF

• 180 liters a day compared to

3 liters of plasma

• The plasma is filtered 60

times a day

• Why do the kidneys have

such a high GFR?
• For most substances, the rates of
filtration and reabsorption are
extremely large relative to the rates
of excretion

• slight changes of filtration or

reabsorption can lead to relatively
large changes in renal excretion

• For example, an increase in

glomerular filtration rate (GFR) of
only 10 percent (from 180 to 198
L/day) would raise urine volume 13-
fold (from 1.5 to 19.5 L/day) if
reabsorption is constant
• Solutes crossing between the
lumen of the tubule and the
blood need to overcome
three main obstacles:

• The tubular epithelium

• The vascular endothelium

• The separating fluid-filled

interstitial space
• In the cortex, the vascular endothelium of
peritubular capillaries is fenestrated:
contains small openings or windows

• Little resistance is offered to the passive

movement of water and small solutes, with
the following consequences:

• Overall transport is mostly governed by

the tubular epithelium

• The small solute osmolality of the

cortical interstitium is equivalent to that
in plasma
• In the medulla, where both blood flow and
transport events are quantitatively lower,
only some regions of the vasculature are
fenestrated

• Consequently:

• The overall transport depends on both

the properties of the tubular
epithelium and the vascular
endothelium

• The medullary interstitium osmolality is

not comparable to plasma osmolality
Ø Solutes can cross the tubular
epithelium in either 1 or 2 steps:

• The paracellular path (1 step),

through the tight junctions between
the cells

• The transcellular path, used more

frequently, in which solutes go
through the cells in 2 steps:

• Through the apical membrane

facing the tubular lumen
• Through the basolateral
membrane facing the interstitium.
• A variety of
mechanisms exists
by which solutes
cross the barriers

• The general classes

of mechanisms are
similar to those
used elsewhere in
the body.
Ø Movement by diffusion

• Diffusion is the net movement of atoms or molecules to regions

of lower concentration, and results from Brownian motion

• Net diffusion occurs across a barrier (ie, more molecules

moving one way than the other) if:

• there exists a driving force, i.e. a concentration or charge

gradient

• the barrier is permeable to the molecules

Ø Movement by diffusion

• Lipid-soluble substances, e.g.

gases or steroids, can diffuse
directly through the lipid
bilayer

• Most biologically-relevant
molecules cannot cross lipid
membranes:

• Specific integral
membrane proteins
(channels and
transporters) are required
Ø Movement by diffusion: channels

• Channels are small pores that switch between an open and a

closed conformation

• They permit water or specific solutes to diffuse through them,

allowing rapid movement of large amounts of a specific
substance

• Examples are the sodium and potassium channels

• Movement through channels is passive, i.e. no energy is

required because of the existence of the gradient
Ø Movement by diffusion: channels

• In the kidneys, permeability of channels is critical for renal

function and is therefore tightly regulated
Ø Movement by diffusion: channels

• Many channels are gated, i.e. opening probability is ↑ or ↓ by:

• reversible binding of small molecules (ligand-gated
channels)
• changes in membrane potential (voltage-gated channels)
• mechanical distortion (stretch-gated channels)

• Many channel types have regulatory phosphorylation sites

• Some channels undergo endocytosis, thus regulating channel

availability

• On a slower time scale, genomic expression is regulated so that

the total number of channels increases or decreases
Ø Movement by diffusion: transporters

• Diffusion may also occur through a uniporter, which allows

• movement of a single solute species through a membrane:
facilitated diffusion, also driven by a gradient

• An example of uniporters crucial for all cells is the GLUT family

Ø Movement by diffusion: transporters

• Compared to channels, many transporters have a lower rate

of transport because:

• the transported solutes bind strongly to the transporter

• the transport protein must undergo conformational change

to move the solute from one side of the membrane to the
other

• As for channels, regulation of transporters includes:

changes in phosphorylation, sequestration into vesicles, changes
in genomic expression
Ø Movement by active transport:

Movement of any solute against its electrochemical gradient

requires energy and is called active transport
Ø Movement by active transport: secondary active transporters

• Some transporters move at least 1 solute down its

electrochemical gradient to provide the energy to move 1 or
more solute(s) against an electrochemical gradient: this is
secondary active transport (ATP not required)

• Energy needed is obtained indirectly from the transport of

another solute (often Na+), and is often higher than the energy
required to move the other solute against its gradient

• Stoiechiometry is important, eg. SGLT moves 2 Na+ è more

energy available to actively transport one glucose molecule
Ø Movement by active transport: Symporters and antiporters

• Symporters and antiporters move 2 or more solute species:

• in the same direction (symporters or cotransport)

• Example: symporters move sodium and glucose together
into cells (members of the SGLT protein family); move
sodium, potassium, and chloride all together into a cell

• in opposite directions (antiporters or counter transport)

• Example: antiporters move sodium into a cell and protons
out of a cell (members of the NHE protein family); chloride
in one direction and bicarbonate in the opposite direction
Ø Movement by transporters: Primary active transporters

• Primary active transporters move 1 or more solute(s) up their

electrochemical gradients, using the energy obtained from the
hydrolysis of ATP

• All transporters that move solutes in this manner are ATPases

• Among the key primary active transporters in the kidney is the

ubiquitous Na+-K+-ATPase (the sodium pump): simultaneously
moves 3 Na+ against their electrochemical gradient out of a cell
and 2 K+ against their gradient into a cell for every ATP molecule
hydrolyzed
Ø Importance of transporters:
Example of the Na+-K+-ATPase

Found on the basolateral sides, it

maintains:
• ↓ intracellular [Na+]
• ↑ intracellular [K+]
• a net negative charge (~-70 mV)
within the cell
• This favors passive diffusion of
Na+ across the luminal
membrane because:
• there is a concentration
gradient
• the - intracellular potential
attracts + charges
Ø Passive water reabsorption by osmosis

• When solutes are transported out of the tubule, their

concentrations inside the tubule ↓ but ↑ in the interstitium

• This creates a concentration difference that causes osmosis of

water in the same direction in which the solutes are transported

• Some parts of the renal tubule, especially the proximal tubule,

are highly permeable to water, and water reabsorption occurs
very rapidly through:
• Tight junctions between epithelial cells: as water moves across
the tight junctions by osmosis, it can carry with it some solutes,
a process referred to as solvent drag
• The cells themselves
Ø Passive water reabsorption by osmosis

• In the more distal parts of the nephron

(beginning in the loop of Henle and
extending through the collecting tubule):

• tight junctions are less permeable to

water and solutes
• epithelial cells have decreased surface
area

• Therefore, water cannot move easily across the tubular membrane

• However, ADH (vasopressin) greatly increases the water

permeability in the distal and collecting tubules
Ø Paracellular transport:

• As water follows Na+ across the epithelium,

the volume remaining in the lumen ↓ ,
concentrating solutes

• This generates a gradient across the tight

junctions between the lumen and
interstitium

• If the tight junctions are permeable

("leaky"), solutes will diffuse from lumen to
interstitium; this applies to many solutes in
the proximal tubule: e.g. urea, K+, Cl-, Ca2+,
and Mg2+
Ø Receptor-mediated endocytosis:

• A solute (usually a protein) binds to a site on the apical surface

of an epithelial cell

• ENDOCYTOSIS: A patch of membrane with the solute is

internalized as a vesicle; the protein is then degraded into
amino acids, which are transported across the basolateral
membrane

• TRANSCYTOSIS: for a few proteins (mainly IGs), intact endocytic

vesicles are transported to the basolateral side and the intact
protein is released

• Important in kidney defense mechanisms

• There are upper limits to the speed with which any given solute
can be reabsorbed from the tubular lumen to capillary

• If limits are reached, the consequence is that less solute is

reabsorbed

• The unabsorbed solutes are left in the lumen to be passed on

to the next nephron segment

• In general, transport mechanisms can be classified by the

properties of these limits as either:

• tubular maximum-limited (Tm) systems

• gradient-limited systems
• Tm systems reach an upper limit because the transporters
moving the substance become saturated
• Any further increase in solute concentration does not increase
the rate at which the substance binds to the transporter
• The upper rate is a property of the transporter

• Gradient-limited systems reach an upper limit because the

tight junctions are leaky
• Any significant lowering of luminal concentration relative to the
interstitium results in a leak back into the lumen as fast as the
substance is transported out
• The upper rate is a property of the permeability of the epithelial
monolayer
Ø Tm-limited systems: Example of glucose

• Glucose is present in plasma at a concentration of about 5

mmol/L and is freely filtered

• It is reabsorbed by the transcellular route

• It enters the epithelial cells across the apical membrane via
a Na+ symporter (SGLT)
• It then exits across the basolateral membrane into the
interstitium via a uniporter (a GLUT protein family member)

• Normally, all the filtered glucose is reabsorbed in the proximal

tubule, with none remaining in the lumen to be passed on to
the loop of Henle
Ø Tm-limited systems: glucose

• If the filtered load of glucose is

abnormally ↑, SGLTs' upper limit
for reabsorption is reached

• That upper limit is the tubular

maximum (Tm) for glucose: the
maximum rate at which it can be
reabsorbed

• Any increase in filtered load above

the Tm results in glucose being
passed on to the loop of Henle,
such as in pathological situations
Ø Gradient-limited systems: example of sodium

• Na+ is freely filtered and present in the luminal fluid at a

concentration of about 140 mEq/L, the same as in plasma

• It is reabsorbed by a variety of pathways described previously:

• Symporters and antiporters in the apical membrane

• Na+-K+-ATPase mainly across the basolateral membrane

Ø Gradient-limited systems: sodium

• As Na+ is transported into the interstitium, the interstitial

concentration begins to ↑ and the luminal concentration ↓

• When the concentration of Na+ reaches a sufficiently low level

in the lumen, the concentration gradient between the
interstitium and the lumen drives:
• a flux of Na+ into peritubular capillaries
• a flux of Na+ back across the tight junctions, i.e. passive
back-leak

• At this point, net transport is zero: the system has established

the largest gradient possible, i.e. its gradient limit

• The leakier the epithelium, the lower is the gradient limit

`
• Diuretics, also called water pills, are
medications designed to increase the
amount of water and salt expelled
from the body as urine

• There are several categories of

diuretics, all of which increase the
excretion of water from bodies,
although each class does so in a
distinct way

• Diuretics are used to treat heart

failure, liver cirrhosis, edema,
hypertension, influenza, water
poisoning, and certain kidney diseases
• Act on the distal convoluted tubule
and inhibit the sodium-chloride
symporter

• This leads to a retention of water in

the urine, as water normally follows
penetrating solutes

• There are both short-term and long-term anti-hypertensive

actions

• Examples of thiazide diuretics: chlorothiazide, chlorthalidone,

hydrochlorothiazide, metolazone, indapamide
• Cause a substantial diuresis – up
to 20% of the filtered load of NaCl
and water (normal reabsorption
leaves 0.4% of filtered sodium in
the urine)

• Inhibit the body's ability to

reabsorb sodium at the ascending
loop in the nephron

• Often used to treat heart failure

• Examples include torsemide, furosemide, bumetanide, ethacrynic

acid
• Do not promote the secretion of potassium
into the urine, preventing certain health
problems such as arrythmias

• two specific classes that have their effect at

similar locations:

• Aldosterone antagonists (e.g.

spironolactone, eplerenone and
potassium canreonate): Aldosterone
adds sodium channels in the principal
cells of the collecting duct and late distal tubule; inhibiting
aldosterone inhibits sodium reabsorption
• Epithelial sodium channel blockers: amiloride and triamterene:
do not lower blood pressure as well
Fanconi
`