WINDSOR UNIVERSITY SCHOOL OF MEDICINE

1. WINDSOR UNIVERSITYSCHOOL OF MEDICINE Renal Physiology Dr.Vishal Surender.MD.

2. Learning Objectives 1. Outline the role of the renal system in control of body fluid composition and in the balance between fluid and electrolyte ingestion and excretion. 2. Describe in sequence the tubular segments through which ultrafiltrate flows from Bowman’s capsule to the ureter. Identify the cortical/medullary location of each renal tubule segment. 3. Compare and contrast the structure and function of cortical and juxtamedullarynephrons. 4. Describe in sequence the blood vessels through which blood flows when passing from the renal artery to the renal vein, including the glomerular blood vessels, peritubular capillaries and vasa recta. 5. Explain the functional significance for glomerular filtration of having arterioles at either end of the glomerular capillary network. 6. List the anatomical elements of the juxtaglomerular apparatus (JGA) and know its major functions are renin secretion and Tubulo-glomerular feedback (TGF). 7. Compare and contrast characteristics of renal oxygen consumption with other organs.

3. Urinary System Introduction • The urinary system rids the body of waste materials and controls the volume and composition of body fluids. Endocrine and Synthetic functions • EPO • Controls RBC production from stem cells in marrow • Stimulated by reduced PO2 in kidney. • Vitamin D • Active form (calcitrol) produced by a hydroxlation in kidney & liver • Important for calcium absorption from GI and also neuronal development in-utero • Renin • An enzyme. Synthesized in juxtaglomerular (granular) cells in afferent arteriole • Stimulated by a fall in circulating volume • Leads to the production of Ang II and Aldosterone

4. Basic Anatomy of the Kidney Renal Hilus: Renal artery, vein, nerves, lymphatics & renal pelvis Cortex Medulla: Renal Pyramids Medullary rays Papilla

5. Internal Structure of the Kidney (85%) (15%)

6. Nephron Structure: Tubular Segments

7. Nephron Structure: Associated Blood Vessels Two arterioles and two capillary beds in series

8. The Kidney Has The Highest Blood Flow Per Unit Mass Among Major Organs 1250 ml/min = 25% of cardiac output

9. Cellular Features of the Renal Corpuscle

10. Filtration Membrane-Schematic

11. Filtration Membrane- Electron Micrograph

12. Cells of the Proximal Convoluted Tubule (PCT)

13. Cells of the Thin Loop of Henle • The key feature of these cells is that they are highly permeable to water but not to solutes. Cells of the Thick Ascending Loop of Henle and DCT • The key feature of the cells of the ascending limb is that they are highly permeable to solutes, particularly sodium chloride, but not to water. The cells of the DCT are more permeable to water than those of the ascending limb.

14. The Juxtaglomerular Apparatus Monitor sodium chloride concentration (juxtaglomerular)baroreceptors renin

15. Cells of the Cortical Collecting Duct:- 1. Principal Cells 2. Intercalated Cells • The key feature of principal cells is that their permeability to water and solutes is physiologically regulated by hormones. • The key feature of intercalated cells is their secretion of hydrogen ions for acid/base balancing.

16. Formation of urine • • Formation of urine by the kidney involves three main processes: • 1. filtration • 2. reabsorption • 3. secretion • • During filtration large quantities of water and solutes pass through the filtration membrane from the blood into the glomerular capsule.

17. no protein Glomerular filtration Afferent arteriole Efferent arteriole Glomerular capillaries Bowman’s space • all other molecules and ions at ~same concentration as plasma

18. The Filtration Membrane and Glomerular Filtration • Passage through the filtration membrane is limited not only on the basis of size but also by charge. • Glomerular filtration is a process of bulk flow driven by the hydrostatic pressure of the blood. • Small molecules pass rapidly through the filtration membrane, while large proteins and blood cells are kept out of the capsular space.

19. Neutral molecule Anion Anion proteinuria Shape Filtration barrier • nephrotic syndrome: • Glomerulonephritis:

20. Glomerular Filtrate • The fluid and solutes collecting in the capsular space is called glomerular filtrate. • The concentration of each of these substances in the glomerular filtrate is similar to its concentration in plasma. Damage to Filtration Membrane • How might the contents of the filtrate be altered if the filtration membrane is damaged or destroyed?

21. Forces Affecting Filtration • There are three forces affecting filtration at the glomerulus: 1. Hydrostatic Pressure within the Glomerular Capillaries (60mmHg) 2. Hydrostatic Pressure in Bowman`s Capsule (15mmHg) 3. Osmotic Pressure within the Glomerular Capillaries (28mmHg) Net Filtration Pressure = 60 mm Hg - (15 mm Hg + 28 mm Hg) = 17 mm Hg “kidney shut-down” or acute renal failure.

22. GFR Measurement of GFR is the best single means of assessing kidney function quantitatively Sum of filtration rates of all the nephrons = total glomerular filtration rate = total GFR = GFR If total number of functioning nephrons is reduced (chronic renal failure) The glomerular filtration rate is directly proportional to the net filtration pressure, so a fluctuation in any of the three pressures previously discussed will change the GFR.

23. Normally, renal blood flow doesn’t change much Flow = Δ Pressure Resistance Renal blood flow GFR 1500 150 ml/min 1000 100 Autoregulation 500 50 100 150 200 50 Mean arterial pressure (mmHg)

24. Flow = Δ Pressure Resistance Afferent arteriole Efferent arteriole Arterial pressure Mechanism? vasoconstriction During autoregulation, as blood pressure increases, so does vascular resistance PGC ↓ • myogenic • tubuloglomerular feedback

25. Myogenic mechanism of autoregulation blood pressure afferent arteriole stretch non-specific cation channels open depolarization calcium channels open afferent arteriole contracts

26. afferent arteriole A1 receptor adenosine ATP Na+ 2Cl- K+ NaCl delivery macula densa cell Tubuloglomerular feedback Vasoconstriction macula densa

27. Autoregulation does not mean that GFR never changes! Renal blood flow 1500 1000 Autoregulation 500 100 150 200 50 Mean arterial pressure (mmHg) • not perfect • not below ~80 mmHg • can be overridden by extrinsic factors (nerves, hormones) 150 ml/min Renal blood flow 100 GFR 50

29. Clearance of x (Cx) = Ux.V Px Renal clearance The renal clearance of a substance is: • “The VOLUME of plasma rendered free of a given • substance in one minute” Substance x: Rate of excretion = Ux.V Plasma concentration = Px = ml/min liters/day gallons/second

30. Questions: • How much urea is excreted per min? • What is the clearance of urea? Purea = 0.2 mg/ml Uurea = 6 mg/ml V = 2ml/min Answers: • Urea excretion = 6 mg/ml x 2 ml/min = 12 mg/min • Urea clearance = 12 mg/min = 60 ml/min i.e. 60 ml of plasma loses its urea into the urine in one minute 0.2 mg/ml

31. Filtration Reabsorption Secretion Excretion Representative Nephron Glomerular capillaries Afferent arteriole Efferent arteriole Renal artery Peritubular capillaries Renal vein

32. 1. Freely filtered 2. Not reabsorbed 3. Not secreted H2O Amount of a excreted per minute = amount of a filtered per minute Uax V = GFa xGFR GFR = Ua x V C1 x V1 = C2 x V2 How to measure GFR Need a substance (a) with special properties: (concentration in Bowman’s space = concentration in plasma) Urine conc. of a x urine flow rate = glomerular filtrate conc. of a x GFR (GFa = Pa) GFa

33. Very few substances meet the criteria required to measure GFR Best known: Inulin • polysaccharide of fructose • molecular weight ~5000 daltons • molecular diameter ~3 nm Typical value for GFR ~120 ml/min ~180 liters/day!

34. Useful alternative: • Freely filtered  • Not reabsorbed  • Not secreted ( true Ccr normally overestimates GFR by ~10-20%) Problems with measuring Cin clinically: • Must be infused intravenously • Continual blood sampling required • Chemical analysis cumbersome Creatinine (notcreatine) • Endogenous (by-product of muscle metabolism) • Released into blood at relatively constant rate (plasma concentration fairly stable; therefore only need one blood sample)

35. Patient (Jim) with suspected renal failure • 24 hour urine volume = 600 mL • Urine [creatinine] = 240 mg/dL • Plasma [creatinine] = 10 mg/dL • BUN = 80 mg/dL (normal 10-20 mg/dL) Calculate his creatinine clearance

36. Ccr = 240 mg/dL x 600 mL/day (0.42 ml/min) 10 mg/dL Low GFR means renal insufficiency Jim’s creatinine clearance (Ccr): Ccr = Ucr x V / Pcr Ccr = 10ml/min (normal = 90-140 mL/min)

37. Autoregulation of GFR During normal conditions, systemic blood pressure registers approximately 120 millimeters of mercury; the diameter of the afferent arteriole is normal, as is the glomerular hydrostatic pressure. These conditions provide a normal glomerular filtration rate of 125 milliliters per minute. During mild exercise  increase in GFR [of 21 milliliters per minute, to 146 milliliters per minute During periods of relaxation  reduction of glomerular hydrostatic pressure and GFR

38. GFR Regulation Mechanisms: Myogenic Mechanism -inherent tendency of vascular smooth muscle cells to contract when stretched. • Stretching the arteriole wall(increasing blood pressure) causes a reflexive vasoconstriction. As long as pressure continues, the vessel will stay constricted. • When pressure against the vessel wall is reduced(decrease in blood pressure), the vessel dilates. Changes in blood pressure therefore directly affect the constriction or dilation of the arteriole, and so glomerular blood flow. Tubuloglomerular Mechanism • A second regulatory mechanism is the sensitivity of the macula densacells of the juxtaglomerular apparatus to the concentration of sodium chloride in the filtrate, which is proportional to the rate of filtrate flow in the terminal portion of the ascending loop of Henle. High Osmolarity and High Rate of Filtrate Flow in Tubule.

39. Low Osmolarity and Low Rate of Filtrate Flow in Tubule • A low rate of filtrate flow and, therefore, low sodium chloride in the terminal portion of the ascending loop of Henle is also sensed by the macula densa cells. This condition is usually the result of low GFR caused by low blood pressure. • In response, these cells initiate two effects: 1) They decrease secretion of the vasoconstrictor chemicals. This leads to dilation of the arteriole and so increases blood flow, glomerular hydrostatic pressure, and the GFR 2) The macula densa cells signal the granular cells of the afferent and efferent arterioles to release renin into the bloodstream. What is the Effect of Renin on the Regulation of the GFR ? 1- angiotensin II formed from renin causes constriction of the efferent arteriole 2- release of the hormone aldosterone

40. GFR Regulation Mechanisms: Sympathetic Nervous System Control Sympathetic nerve fibers innervate all blood vessels of the kidney as an extrinsic regulation mechanism. During normal daily activity they have minimal influence. However, during periods of extreme stress or blood loss, sympathetic stimulation overrides the autoregulatory mechanisms of the kidney. • Increased sympathetic discharge causes intense constriction of all renal blood vessels. Two important results occur: 1) The activity of the kidney is temporarily lessened or suspended in favor of shunting the blood to other vital organs 2) The lower GFR reduces fluid loss, thus maintaining a higher blood volume and blood pressure for other vital functions. • Reduction in filtration cannot go on indefinitely, as waste products and metabolic imbalances increase in the blood. Autoregulation mechanisms are now ineffective in preventing acute renal failure. • When fluid is given intravenously, the blood volume increases. With increasing blood volume there will be gradual rise in blood pressure, reduction in sympathetic discharge, and restoration of renal functioning.

41. Early Filtrate Processing • Once the filtrate is formed, the early tubular segments of the nephronreabsorb solutes and water back into the blood to restore its volume and composition. • • They also remove some solutes from the blood and secrete them into the filtrate to fine tune the blood’s composition. Reabsorption Pathways • To be reabsorbed into the blood, substances in the filtrate must cross the barrier formed by the tubular cells. • • There are two reabsorption pathways: • 1. the transcellular pathway • 2. the paracellular pathway

42. Reabsorption Overview: • What is the driving force for movement of water and solutes across cells in nephron tubules/Reabsorption? • • The transport of sodium ions has two important direct results: • 1) The interstitial osmolarity increases, causing water to diffuse out of the tubular lumen • 2) the lowered intracellular concentration causes additional sodium ions to be reabsorbed through the luminal membrane. • • This provides more sodium ions to be actively transported and enables the cycle to repeat. • • In addition sodium ion transport enables the reabsorption of most substances in the nephron.

43. PCT Basolateral Membrane: Active Transport • The renal tubules are composed of specialized cells in each region that accomplish a different stage of filtrate processing. • The proximal convoluted tubule is where major reabsorption of valued substances occurs. Activities occurring at the basolateral membrane of the tubular cells. • The reabsorption of many substances from the glomerular filtrate in the PCT depends directly or indirectly on the activereabsorption of the sodium ion. • The cellular structure responsible for this process is the sodium/potassium ATPase ion pump located in the basolateral membrane. • Using energy from ATP, the ion pump carries out primary active transport of sodium ions out of the cell and potassium ions into the cell. - net effect of the ion pump’s activity

44. PCT Basolateral Membrane: Diffusion • • There are two additional transmembrane proteins in the basolateral membrane: • 1. a potassium ion channel • 2. a glucose carrier molecule • • The glucose carrier molecule binds only to glucose, and transports it across the basolateral membrane by a passive mechanism called facilitated diffusion. Glucose can move either into or out of the cell, depending on its concentration. • • The potassium ion channel lets most of the potassium ions diffuse from the tubular cells back into the interstitium. It prevents the sodium-potassium ATPase ion pump from causing potassium ion depletion in the blood or excess accumulation in the cells.

45. PCT Luminal Membrane Activity Transport proteins at the luminal membrane of the proximal convoluted tubule:- 1) sodium-hydrogen countertransport carrier molecule 2)sodium/glucose cotransport carrier molecules. • The activity of all these carrier molecules depends on sodium-potassium ATPase ion pump activity in the basolateral membrane. Sodium Channels Sodium ions are transported by simple diffusion through sodium channels on luminal membrane. Sodium-Hydrogen Countertransport Molecule. is an example of secondary active transport driven by the primary active transport of the basolateral membrane. The hydrogen ion being secreted here is generated in the cell for acid/base balancing purposes.

46. Sodium-Glucose Cotransport Carrier Molecule. The cotransport (or symport) carrier molecules carry both sodium and glucose into the cell. The reabsorption of glucose depends on the movement of a sodium ion down its concentration gradient from high extracellular to low intracellular concentrations. This is an example of secondary active transport. Glucose now moves down its concentration gradient to the basolateral membrane, where it is transported into the interstitium by facilitated diffusion as seen previously. Transport Maximum, or Tm. For most actively reabsorbed solutes, the amount reabsorbed in the PCT is limited only by the number of available transport carriers for that specific substance. This limit is called the transport maximum, or Tm. If the amount of a specific solute in the filtrate exceeds the transport maximum, the excess solute continues to pass unreabsorbed through the tubules and is excreted in the urine. The Effect of Hyperglycemia • Glucose is vital to the body’s normal functioning. However, in hyperglycemia, a condition that accompanies the disease diabetes mellitus, excess glucose accumulates in the blood. • If the number of cotransport molecules is not sufficient to handle an abnormally high concentration of glucose in the filtrate, the transport maximum is exceeded and the ‘extra’ glucose will be excreted in the urine.