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Medulla: The inner region, consisting of zones known as „pyramids‟ which surround
the pelvis. The Loop of Henle and collecting ducts of the nephron are located here.
Pelvis: The central cavity. Urine formed after blood is cleansed is deposited here. This
cavity is continuous with the ureter so the urine goes directly to the bladder.
A DIAGRAM OF THE INTERNAL STRUCTURE
OF THE KIDNEY
THE NEPHRON
The nephron is the functional unit found within
the kidneys. Each kidney is made up of millions
of microscopic nephrons, each with a rich blood
supply. To fully understand the function of the
kidney, the function of the nephron must be
studied and understood since it is this structure
that carries out excretion and osmoregulation.
DIAGRAM OF A NEPHRON
DIAGRAM OF A NEPHRON
Each nephron has the following structures:
•Loop of Henle
•Collecting duct
BOWMAN‟S CAPSULE
Glomerulus: A mass of capillaries enclosed by the
Bowman‟s capsule.
Podocytes: these are found on the inner wall of the Bowman‟s capsule
and are foot-like cells with many processes that wrap around the
capillary. There are gaps between the branches of the cell which
enables the free flow of substances that have passed through the
basement membrane, into the Bowman‟s capsule.
Diagrams of the podocytes and basement
membrane
Podocyte:
BASEMENT MEMBRANE
THE PROXIMAL CONVOLUTED TUBULE
This is the longest part of the nephron and is located in
the cortex of the kidney. It is surrounded by many
capillaries that are very close to the walls. Approximately
80% of the glomerular filtrate is reabsorbed here via
selective reabsorption. Cubical epithelial cells line the
tubule walls and have many microvilli on their free
surfaces which increase the surface area of the wall
exposed to the filtrate.
Fact: The total surface area of the Human proximal tubule
cells is 50m2!!!
There is a rich blood supply surrounding each
nephron, which is important for the
reabsorption process. The cubical epithelial
cells lining the tubule invaginates to form
intercellular and subcellular spaces next to the
basement membrane of the capillaries. Glucose
and amino acids are absorbed into the blood by
active transport across the infolded membranes
and subcellular spaces. These solutes diffuse
from the filtrate into the cells, then through to
the subcellular spaces and then into the
bloodstream. This sets up a concentration
gradient which is maintained as the reabsorbed
solutes are carried away by the flowing blood.
Other mineral ions are also actively reabsorbed the way
glucose and amino acids are. As so many of the solutes are
removed, the filtrate becomes hypotonic (lower
concentration of solute molecules) than the surrounding
blood, stimulating water to move via osmosis from the
filtrate to the blood. This leads to the filtrate and the blood
being isotonic (same solute concentrations) by the time the
filtrate reaches the end of the tubule. However, since urea is
not actively reabsorbed, its concentration in the filtrate is
much higher than in the blood and some of the urea
unavoidably diffuses back into the bloodstream and is taken
away.
THE LOOP OF HENLE
This hairpin-bend structure has a descending limb
and an ascending limb and is found in the
medulla of the kidney. The descending limb has
thin walls permeable to water and penetrates deep
into the medulla but the ascending limb has
thicker, relatively impermeable walls that returns
to the cortex. Surrounding the loop is a network
of capillaries, one part of which has the same
hairpin structure and is called the vasa recta.
Terminology:
Solution with greater Solution with lower
concentration of solute concentration of solute
molecules molecules
Lower concentration of water Higher concentration of
molecules water molecules
Lower solute potential Higher solute potential
Lower water potential Higher water potential
hypertonic hypotonic
Need to know:
The loop of Henle works by making the concentration
of the interstitial tissues of the medulla hypertonic
(greater solute concentration) to the filtrate by actively
transporting chloride ions out of the filtrate into the
surroundings. Sodium ions passively follow. This occurs
in the thick part of the ascending limb.
The deeper part of the medulla near the pelvis is the
most concentrated and therefore has the lowest water
potential.
The filtrate at the end of the proximal convoluted tubule,
entering the loop of Henle is isotonic. As it descends the loop,
it is carried through tissues of increasing solute concentration
and the permeable walls of the descending limb enables water
to leave the filtrate by osmosis and enter the surrounding
tissues. This water passes into the vasa recta and is carried
away in the blood, and this is possible because blood in the
vasa recta is flowing from deeper more concentrated regions
of the medulla so its water potential is lower than the filtrate
of the adjacent descending limb.
The continuous loss of water in the descending limb
causes the filtrate to have the same water potential as the
surrounding tissues by the time it reaches the hairpin bend,
both of which are hypertonic to the blood. The active removal
of sodium chloride in the ascending limb leaves the filtrate
hypotonic to the blood as it enters the distal convoluted
tubule.
The tissues then become more concentrated than the filtrate
which would normally lead to osmosis but water is
prohibited from leaving because of the impermeable walls
of the ascending limb.
Glomerular filtration.
Tubular reabsorption
Tubular secretion
BASIC RENAL PROCESS
Urine formation:
Filtration from of plasma
from the glomerular
capillaries into the
Bowman‟s space.
Movement from the tubular
lumen to the peritubular
capillaries is the process
called tubular reabsorption
Movement from the
peritubular capillaries to the
tubular lumen is the process
known as tubular secretion
Once in the tubule the
substance need not be
excreted , it can be
reabsorbed.
These processes do not
apply to all substances.
E.g.
- Glucose (completely
reabsorbed.)
- Toxins ( Secreted and not
reabsorbed)
A specific combination of glomerular filtration ,
tubular reabsorption and tubular secretion applies to
different substances found in the plasma.
It is important to note that the rates of these processes
are subject to physiological control.
The rates of these processes will therefore be changed
in order to ensure homeostatic regulation.
A forth process is also important to some substances,
this is known as metabolism by the tubular cells.
Glomerular Filtration
The filtration of plasma from the glomerular capillaries into the
Bowman‟s space is termed glomerular filtration.
The filtrate is termed glomerular filtrate or ultrafiltrate
Glomerular filtration is a bulk flow process
Filtrate contains all plasma substances except protein.
Table 1 : Constituents of the Glomerular filtrate
Filtered Not filtered
Low molecular weight Most plasma proteins ie.
substances (including Albumins & Globulins.
smaller peptides)
water Plasma calcium and fatty acids
( Widmaier E. et al,
2008)
RATE OF GLOMERULAR
FILTRATION ( GFR )
GFR : the volume of fluid filtered from the glomeruli
into the Bowman‟s space per unit time
Determined by :1. Net filtration pressure
2. Permeability of the corpuscular
membranes
3. Surface area available for filtration
GFR is not fixed but is subject to physiological
regulation , which causes a change in the net filtration
pressure due to neural and hormonal input to the
afferent and efferent arterioles.
Decreased GFR Increased GFR
Constriction if afferent Constriction of the efferent
arteriole causes a decrease in arteriole results in an
hydrostatic pressure in the increase in hydrostatic
glomerular capillaries, this pressure in the glomerular
results in decreased GFR capilleries. Results in
Dilation of the efferent increased GFR
arteriole results in a Dilation of afferent arteriole
reduction in hydrostatic causes an increase in
pressure in the glomerular hydrostatic pressure in the
capillaries resulting in a glomerular capilleries. This
decreased GFR results in an increase in GFR
Tubular Reabsorption
Movement of substances from the tubular lumen to the
interstitial fluid does not occur by bulk flow due to
inadequate pressure differences and permeability of the
tubular membranes
Tubular reabsorption involves the reabsorption of certain
substances out of filtrate by either diffusion or mediated
transport
Substances are then returned to capillary blood which
surround the kidney tubules.
Tubular reabsorbtion mainly occurs in the Proximal tubule
and the Loop of Henele
Data for a few
plasma components
that undergo
filtration and
reabsorption .
(Widmaire E. et al ,
2008)
Diffusion usually occurs across the tight junctions connecting
the epithelial cells
Mediated transport requires the participation of transport
protiens in the membranes of the tubular cells.
Gastrointestinal Tract
Urinary Tract
Menstrual Flow
Fig : Average Daily Water Gain and Loss in
Adults
( Widmaier E. , 2008)
Water loss from skin and lining of respiratory tract is
known as insensible water loss
Water loss from gastrointestinal tract can be made severe
in diarrhoea.
Small quantities of Sodium and Chloride are excreted
from skin and gastrointestinal tract.
During severe sweating , diarrhoea ,vomiting and
hemorrhage increased amounts of sodium and chloride are
excreted.
Fig: Daily Sodium Chloride Intake and Loss
(Widmaier , E. , 2008)
From Figure 1 and 2 it is seen that salt and water losses
equal salt and water gains.
This is as a result of regulation of urinary loss.
Healthy normal kidneys can readily alter the excretion of
salt and water to ensure loss is balanced with gain
Sodium and water are filtered from the glomerular
capillaries and into the Bowman‟s space
In the CCD sodium enters from the tubular lumen and into
the cell via diffusion through sodium channels
Coupling of Water Reabsorption to
Sodium Reabsorption
Sodium is transported from the tubular lumen to the
intersitial fluid across the epithelial cells
Blood enters the vessel loop and flows down deeper and
deeper while sodium and chloride diffuse into the blood
while water diffuses out
Stretch receptors
(baroreceptors) that are
sensitive to changes in blood
pressure and central blood
volume aid in the regulation
of ADH release.
The hormones interact when
blood loss or dehydration
occurs to maintain
intravascular volume.
FIGURE 20
FIGURE 21
Sodium Regulation
The kidney monitors arterial pressure and retains sodium
when the arterial pressure is decreased and eliminates it
when the arterial pressure is increased
Sodium reabsorption is an active process occurring in all
tubular segments except the descending limb of the loop
of Henle.
Water reabsorption is by diffusion and is dependent upon
sodium reabsorption.
The primary mechanism driving all transport in the
proximal tubule is the Na-K ATPhase mechanism located
on the basolateral membrane of the tubular cells.
Sodium Regulation(cont’d)
The rate at which the kidney excretes or conserves sodium
is coordinated by the sympathetic nervous system and the
renin-angiotensin-aldosterone system.
When Na + concentration falls, blood pressure and volume
falls because water is lost with the Na +.
The fall in blood pressure causes renin to be released into
the bloodstream where it catalyses the conversion of the
plasma proteins into angiotensin.
The angiotensin stimulates the adrenal cortex to secrete
aldosterone.
Reabsorption of Na + is accompanied by the loss of K +
(Na + - K + balance).
Sodium Regulation
(cont’d)
The sympathetic nervous system responds to changes in
arterial pressure and blood volume by adjusting the GFR
and the rate at which sodium is filtered from the blood.
Sympathetic activity also regulates tubular reabsorption of
sodium and renin release.
The reninangiotensin- aldosterone system exerts its
action through angiotensin II and aldosterone .
Angiotensin II acts directly on the renal tubules to increase
sodium reabsorption. It also acts to constrict renal blood
vessels, thereby decreasing the glomerular filtration rate
and slowing renal blood flow so that less sodium is filtered
and more is reabsorbed. Angiotensin II is also a powerful
regulator of aldosterone, a hormone secreted by the adrenal
cortex.
FIGURE 22
Sodium Regulation(cont’d)
Aldosterone acts at the level of the cortical collecting
tubules of the kidneys to increase sodium reabsorption
while increasing potassium elimination.
It increases the uptake of Na by the and reabsorption in
the kidneys which causes the concentration of Na+ in the
blood to rise. This method of control depends on a
feedback.
If the concentrations of Na + is too high, the adrenal
cortex becomes inhibited and secretes less aldosterone
and vice verse.
Feedback involves the co-factor renin which is released in
the afferent glomerular arerioles.
Sodium Regulation(cont’d)
Na + is transported out of the cell into the paracellular
space and K + into the cell.
This reduces the cell Na + concen. and the raises the K +
concen.
This causes a concentration gradient in which the presence
of K conductance renders the cell electrically negative wrt
its surroundings.
In a steady state the pump operates below saturation point
for Na + and an increase in Na + entry across the apical
membrane increases the pump rate.
The proximal tubule sodium reabsorption drives the
reabsorption of the cotransported substances (glucose and
the secretion of hydrogen ions.
Renal water regulation
Water excretion is the difference between the volume
of water filtered (the GFR) and the volume reabsorbed
Two mechanisms which assist in the regulation of body
water are: thirst and antidiuretic hormone (ADH).
Thirst is the primary regulator of water intake and ADH is
a regulator of water output. The both respond to changes
in extracellular osmolarity and volume.
Thirst is an emergency response which is controlled by the
hypothlamus. An important stimulus for thirst is
angiotensin II, which becomes increased in response to
low blood volume and low blood pressure.
ADH acts throught two receptors (V1) and (V2) of which
the (V2) are located on the tubular cells of the cortical
collecting duct.
Renal water regulation (cont’d)
They control water reabsorption by the kidneys.
ADH binds to the V2 receptors which increase the
permeability of the collecting duct to water (antidiuretic
effect). The receptor is coupled via a GTP-requiring
stimulatory protein (Gs protein) to the enzyme adenylyl
cyclase.
The enzyme stimulates the production of cyclic AMP
which activates protein kinase A. This kinase induces the
insertion (exocytosis) of water channels, aquaporin 2.
Aquaporin 2 (from the V2 receptors) move from the
cytoplasm of the cells of the collecting duct to the huminal
surface of these cells.
Renal water regulation (cont’d)
Aquaporins 3 and 4 form the water channels in the
basolateral membrane of the principal cells. These are not
regulated by ADH (they are constitutively active).
These channels then allow free movement of water from
the tubular lumen into the cells along a concentration
gradient.
When ADH is not stimulated, the aquaporin 2 channels
readily move out f the apical membrane so that water is no
longer transferred out of the collecting duct.
Without ADH, the permeability of the collecting duct to
water is very low; this results in polyuria.
The mechanism of action of ADH on principle cells, V2=
vasopressin2 receptor, AQ2= aquaporin 2
Potassium Regulation
Increases or decreases in extracellular potassium
concentration can cause abnormal rhythms of the
heart (arrhythmias) and abnormalities of skeletal-
muscle contraction.
Potassium levels are largely regulated by renal
mechanisms that conserve or eliminate potassium.
Major route for elimination is the kidney.
Regulation is controlled by secretion from the blood
into the tubular filtrate rather than vice versa.
Potassium Regulation (cont’d)
Potassium is filtered in the glomerulus, reabsorbed
along with sodium and water in the proximal
tubule and with sodium and chloride in the thick
ascending loop of Henle, and then secreted into
the late distal and cortical collecting tubules for
elimination in the urine.
Aldosterone plays an essential role in regulating
potassium elimination by the kidney. In the presence
of aldosterone, sodium is transported back into the
blood and potassium is secreted into the tubular
filtrate for elimination in the urine (N+- K+ shift).
Potassium Regulation (cont’d)
When body potassium is increased, extracellular potassium
concentration increases. This increase acts directly on the
cortical collecting ducts to increase potassium secretion and
also stimulates aldosterone secretion, the increased plasma
aldosterone then also stimulating potassium secretion.
There is also a (K+- H+)exchange system in the collecting
tubules of the kidney. When serum potassium levels are
increased, potassium is secreted into the urine and hydrogen is
reabsorbed into the blood, producing a decrease in pH and
metabolic acidosis. Conversely, when potassium levels are low,
potassium is reabsorbed and hydrogen is secreted into the
urine, leading to metabolic alkalosis.
Bibliography
cikgurozaini.blogspot.com
apbrwww5.apsu.edu
http://www.nda.ox.ac.uk/wfsa/html/u09/u09_017.htm
Outline
What are diuretics?
How do they work and what are some examples of
diuretics?
What are some clinical situations in which diuretics are
used?
Diuretics
These are agents which increase the mobilization of extra
cellular fluid(ECF) this usually involves the loss of ions
and water
These include
Heart Failure with Edema
Hypertension
Diuretics
Heart Failure with Edema
Decrease cardiac output causes the kidney to
respond as if there is decreased blood volume
Retention of more salt and water
Increase in blood volume to heart
increase vascular volume resulting in edema
Chronic
Diabetes
Hypertension
The kidney has the ability when renal injury occurs, the
GFR is maintained
Vascular disease
Hypertension
Tubulointerstitial disease
Drugs (eg, sulfa, allopurinol)
However when the GFR falls to less than 20-25 mL/min there
is decreased ability of the kidneys to excrete potassium.
Resulting in Hyperkalemia
Chronic Kidney disease
Salt and water handling abnormalities
As kidney function declines, there is excessive sodium
retention which will cause extracellular volume
expansion leading to peripheral edema
Kidney Disease
Chronic
Anemia
Kidney disease
This develops from decreased renal synthesis of
erythropoietin, the hormone responsible for bone marrow
stimulation for red blood cell (RBC) production.
Chronic Kidney disease
Chronic Kidney disease
Bone disease
Renal bone disease is a common complication of chronic
kidney disease.
Decreased renal synthesis of 1,25-
dihydroxycholecalciferol (calcitriol)
Hypocalcaemia develops primarily from decreased
intestinal calcium absorption because of low plasma
calcitriol levels
Kidney Disease
Kidney Disease
References:
Vander‟s Human Physiology 10th Edition, Eric P. Widmaier, Hersel Raff, Kevin T. Strang
http://emedicine.medscape.com/article/238798-overview#a0104
http://en.wikipedia.org/wiki/File:Gray1128.png
http://kidney.niddk.nih.gov/kudiseases/pubs/proteinuria/
http://3.bp.blogspot.com/_kaQ5P19FVgk/SwWAH4PM9kI/AAAAAAAAETw/hkXpMi1NQGQ/s
400/ProximalConvolutedTubule.JPG
http://www.google.tt/imgres?q=cortical+collecting+duct&hl=en&rlz=1C1_____en-
GBTT437TT437&biw=1024&bih=456&tbm=isch&tbnid=8V5ptLll587HQM:&imgrefurl=http://o
pen.jorum.ac.uk/xmlui/bitstream/handle/123456789/947/Items/S324_1_section8.html&docid=Fpt
ccfGU81hJJM&w=510&h=588&ei=W3R6TsXKI8Xc0QGH1byoAg&zoom=1&iact=hc&vpx=67
0&vpy=111&dur=944&hovh=239&hovw=208&tx=113&ty=155&page=1&tbnh=115&tbnw=100
&start=0&ndsp=11&ved=1t:429,r:9,s:0
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GBTT437TT437&biw=1024&bih=499&tbm=isch&prmd=imvns&tbnid=eKM4E-
R07hFL1M:&imgrefurl=http://www.uic.edu/classes/bios/bios100/lecturesf04am/lect21.htm&doci
d=1qQumxeqTWij_M&w=360&h=440&ei=q_p8TqijIafj0QHm7-
znDw&zoom=1&iact=hc&vpx=106&vpy=139&dur=1451&hovh=248&hovw=203&tx=113&ty=
189&page=1&tbnh=144&tbnw=118&start=0&ndsp=8&ved=1t:429,r:4,s:0
Kidney Disease
http://www.google.tt/imgres?q=renal+corpuscle+diagram&hl=en&rlz=1C1_____en-
GBTT437TT437&biw=1024&bih=456&tbm=isch&tbnid=9gXIjDjjaMJvqM:&imgrefurl
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cn/lectures/urinary_physiology.html&docid=0v09nrgwAWVXNM&w=707&h=515&ei=
YPt8TtvxMKTv0gHF-
LDaDw&zoom=1&iact=hc&vpx=91&vpy=167&dur=109&hovh=192&hovw=263&tx=1
27&ty=199&page=1&tbnh=120&tbnw=165&start=0&ndsp=11&ved=1t:429,r:5,s:0
http://www.google.tt/imgres?q=renal+corpuscle+diagram&hl=en&rlz=1C1_____en-
GBTT437TT437&biw=1024&bih=456&tbm=isch&tbnid=boI10CF6dX0OVM:&imgref
url=http://apbrwww5.apsu.edu/thompsonj/Anatomy%2520%26%2520Physiology/2020/2
020%2520Exam%2520Reviews/Exam%25204/CH25%2520Nephron%2520I%2520-
%2520Renal%2520Corpuscle.htm&docid=RdYeUelnc4_AbM&w=699&h=383&ei=YPt
8TtvxMKTv0gHF-
LDaDw&zoom=1&iact=hc&vpx=77&vpy=144&dur=94&hovh=166&hovw=303&tx=18
2&ty=95&page=1&tbnh=97&tbnw=177&start=0&ndsp=11&ved=1t:429,r:0,s:0
DIABETES MELLITUS
A common cause of renal failure is uncontrolled diabetes
mellitus
Diabetes meaning “running through” denotes increased urinary
volume excreted by the persons suffering with this disease.
Diabetes can be due to:
1. Deficiency of insulin
2. Decreased responsiveness to insulin
This abnormality in carbohydrate metabolism leads to high
levels of blood glucose which can lead to considerable damage
to many parts of the body.
These include kidneys, heart ,eyes and blood vessels.
How does Diabetes affect the
Kidneys
Recall : 1. Osmotic diuresis , this is the increased urine
flow as a result of a primary increase in the solute
excretion.
2. Glucose is reabsorped by the proximal tubule
via sodium- glucose transport proteins.
The increase in blood glucose causes an increase in the
rate filtration.
This increase in rate of filtration causes increased amounts
of protein to be filtered across the glomerular membranes.
Small amounts of protein eventually appear in the urine.
The filtered protein leads to increased damage to the
membranes of the renal corpuscle .
How does Diabetes affect the
Kidneys
As the kidneys become more compromised larger
amounts of protein is allowed to pass from the blood
and be excreted in the urine. Leads to proteinuria
Kidney function begins to deteriorate.
Irreversible damage to the kidneys leads to toxic
waste not being able to be filtered out of blood and
dialysis is required.
This is the usual course of diabetic necropathy which
results in end stage kidney disease.
How Diabetes affect the Kidneys
Diabetic necropathy is the disease of the capillaries in
the kidney glomeruli. That is they show
glomerulosclerosis , which is the hardening of the of
the glomerulus of the kidney due to scarring.
Diabetic necropathy is progressive and results in death
2 – 3 years after diagnosis. It is also the leading cause
of premature death in young diabetics.
How does Diabetes affect the
Kidneys
When the blood sugar level of a person rises the
glucose is detected in the urine.
That is there is an increased glucose load in the
proximal tubule. Some glucose therefore escapes
reaborption and causes a retention of water in the
lumen.
This water is excreted along with the glucose.
Persons with diabetes usually excrete large amounts
of urine.
Diabetes insipidus
Diabetes insipidus is caused by the failure of the posterior
pituitary to release the hormone vasopressin or the
inability of the kidney to respond to vasopressin.
RECALL: Water reabsorption in the last portions of the
tubules and coritcal collecting ducts can vary greatly due
to physiological control. The major control is the peptide
hormone vasopressin or antiduretic hormone (ADH)
- [vasopressin] results in an in water permeability
- [vasopressin] results in an in water permeability
In patients with diabetes insipidus the kidneys are
therefore unable to conserve water
Diabetes insipidus
Therefore large quantities of dilute urine is produced.
Persons who have diabetes insipidus will consume
more water
May also suffer from dehydration
Kidney Stones
Increase plasma
angiotensin II
Adrenal cortex
Increase aldosterone secretion
Increase plasma
aldosterone
Increased
Decreased sodium Potassium
excretion excretion
Hypertension
Commonly known as high blood pressure.
Normal blood pressure should be 120/80, any
persons with a systolic pressure over 140 or a
diastolic pressure over 90 is considered to have high
blood pressure.
How does hypertension affect the
kidneys
Hypertension causes an
increase in the work done
by the heart.
Over time blood vessels in
the body become
damaged.
The damage of the blood
vessels of the kidney will
lead to the deterioration of
kidney function, that is
they stop removing waste
and extra fluid.
How does hypertension affect the
kidneys
The extra fluid in the fluid in the blood vessels may further
raise the blood pressure , resulting in a dangerous cycle.
High blood pressure is one of the leading causes of kidney
failure, also known as end stage renal disease.
References
http://www.froedtert.com/SpecialtyAreas/Endocrinology/P
rogramsandDiseaseTreatment/EndocrineHypertension.htm
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001493/
http://ehealthmd.com/content/how-do-kidney-stones-form
http://www.biotecnika.org/blog/vishtiw/diabetes-mellitus-
and-its-effect-kidney-and-liver