C H A P T E R 2 6

Urine Formation by the Kidneys:

I. Glomerular Filtration, Renal

Blood Flow and Their Control

Multiple Functions of the

Kidneys in Homeostasis

The kidneys serve multiplefunctions, including the following:

  1. Excretion of metabolic waste products and foreign chemicals
  2. Regulation of water and electrolyte balances
  3. Regulation of body fluid osmolality and electrolyte concentrations
  4. Regulation of arterial pressure
  5. Regulation of acid-base balance
  6. Secretion, metabolism and excretion of hormones
  7. Gluconeogenesis

1- Excretion of Metabolic Waste Products, Foreign Chemicals, Drugs and Hormone Metabolites.

The kidneys are the primary means for eliminating waste products ofmetabolism that are no longer needed by the body.These products include:

  • urea(from the metabolism of amino acids),
  • creatinine(from muscle creatine),
  • uricacid(from nucleic acids),
  • end products of hemoglobin breakdown(such asbilirubin) and
  • metabolites of various hormones.

These waste products must beeliminated from the body as rapidly as they are produced.

The kidneys alsoeliminate most toxins and other foreign substances that are either produced bythe body or ingested, such as pesticides, drugs and food additives.

2- Regulation of Water and Electrolyte Balances.

For maintenance of homeostasis, excretionof water and electrolytes must precisely match intake. If intake exceedsexcretion, the amount of that substance in the body will increase. If intake isless than excretion, the amount of that substance in the body will decrease.

Intake of water and many electrolytes is governed mainly by a person’s eatingand drinking habits, requiring the kidneys to adjust their excretion rates tomatch the intake of various substances.

Figure 26–1 shows the response of thekidneys to a sudden 10-fold increase in sodium intake from a low level of30mEq/day to a high level of 300mEq/day.Within 2 to 3 days after raising thesodium intake, renal excretion also increases to about300mEq/day, so that a balance between intake andoutput is re-established. However, during the 2 to 3days of renal adaptation to the high sodium intake,there is a modest accumulation of sodium that raisesextracellular fluid volume slightly and triggers hormonalchanges and other compensatory responsesthat signal the kidneys to increase their sodiumexcretion.

The capacity of the kidneys to alter sodium excretion
in response to changes in sodium intake is enormous.
Experimental studies have shown that in many
people, sodium intake can be increased to 1500 mEq/
day (more than 10 times normal) or decreased to
10 mEq/day (less than one tenth normal) with relatively
small changes in extracellular fluid volume or
plasma sodium concentration. This is also true for
water and for most other electrolytes, such as chloride,
potassium, calcium, hydrogen, magnesium and phosphateions.

3- Regulation of Arterial Pressure.

  • The kidneys play a dominant role in long-term regulationof arterial pressure by excreting variable
    amounts of sodium and water.
  • The kidneys also contributeto short-term arterial pressure regulation by secreting vasoactive factors or substances, such asrenin, that lead to the formation of vasoactive products(e.g., angiotensin II).

4- Regulation of Acid-Base Balance.

The kidneys contributeto acid-base regulation, along with the lungs and bodyfluid buffers, by excreting acids and by regulating thebody fluid buffer stores.

The kidneys are the onlymeans of eliminating certain types ofacids, such as sulfuric acid and phosphoric acid, generatedby the metabolism of proteins.

5- Regulation of Erythrocyte Production.

The kidneys secreteerythropoietin, which stimulates the production of redblood cells. One importantstimulus for erythropoietin secretion by the kidneys ishypoxia. The kidneys normally account for almost allthe erythropoietin secreted into the circulation.

Inpeople with severe kidney disease or who have hadtheir kidneys removed and have been placed onhemodialysis, severe anemia develops as a result ofdecreased erythropoietin production.

6- Regulation of 1,25–Dihydroxyvitamin D3

Production.

Thekidneys produce the active form of vitamin D, 1,25-dihydroxyvitamin D3 (calcitriol), by hydroxylating thisvitamin at the “number 1” position.

Calcitriol is essentialfor normal calcium deposition in bone and calciumreabsorption by the gastrointestinal tract.

Calcitriol plays an important role incalcium and phosphate regulation.

7- Glucose Synthesis.

The kidneys synthesize glucose fromamino acids and other precursors during prolongedfasting, a process referred to as gluconeogenesis. Thekidneys’ capacity to add glucose to the blood duringprolonged periods of fasting rivals that of the liver.

Kidneys Homeostatic Failure

  • With chronic kidney disease or acute failure of thekidneys, these homeostatic functions are disrupted and severe abnormalities of body fluid volumes andcompositions rapidly occur.
  • With complete renalfailure, enough potassium, acids, fluid and other substancesaccumulate in the body to cause death withina few days, unless clinical interventions such ashemodialysis are initiated to restore, at least partially,the body fluid and electrolyte balances.

Physiologic Anatomyof the Kidneys

General Organization of the

Kidneysand Urinary Tract

The two kidneys lie on the posterior wall of theabdomen, outside the peritoneal cavity.

Each kidney of the adult human weighs about 150grams and is about the size of a clenched fist. Themedial side of each kidney contains an indented regioncalled the hilumthrough which pass the renal arteryand vein, lymphatics, nerve supply and ureter, whichcarries the final urine from the kidney to the bladder,where it is stored until emptied.

The kidney is surroundedby a tough, fibrous capsulethat protects itsdelicate inner structures. If the kidney is bisected from top to bottom, the twomajor regions that can be visualized are the outercortexand the inner region referred to as the medulla.The medulla is divided into multiple cone-shapedmasses of tissue called renal pyramids. The base ofeach pyramid originates at the border between thecortex and medulla and terminates in the papilla,which projects into the space of the renal pelvis, afunnel-shaped continuation of the upper end of theureter. The outer border of the pelvis is divided intoopen-ended pouches called major calycesthat extenddownward and divide into minor calyces, which collecturine from the tubules of each papilla. The walls of thecalyces, pelvis and ureter contain contractile elementsthat propel the urine toward the bladder, where urineis stored until it is emptied by micturition.

Renal

Blood Supply

Blood flow to the two kidneys is normally about 22 percent of the cardiac output, or 1100 ml/min. The renalartery enters the kidney through the hilum and thenbranches progressively to form the interlobar arteries,arcuate arteries, interlobular arteries (also called radialarteries) and afferent arterioles, which lead to theglomerular capillaries, where large amounts of fluidand solutes (except the plasma proteins) are filtered tobegin urine formation (Figure 26–3).

The distal ends ofthe capillaries of each glomerulus coalesce to form theefferent arteriole, which leads to a second capillarynetwork, the peritubular capillaries, that surrounds therenal tubules.

The renal circulation is unique in that it has two capillarybeds, the glomerular and peritubular capillaries,which are arranged in series and separated by theefferent arterioles, which help regulate the hydrostaticpressure in both sets of capillaries. High hydrostaticpressure in the glomerular capillaries (about60 mmHg) causes rapid fluid filtration, whereas amuch lower hydrostatic pressure in the peritubularcapillaries (about 13 mm Hg) permits rapid fluid reabsorption.

By adjusting the resistance of the afferentand efferent arterioles, the kidneys can regulate thehydrostatic pressure in both the glomerular and theperitubular capillaries, thereby changing the rateglomerular filtration, tubular reabsorption, or both inresponse to body homeostatic demands.

The peritubular capillaries empty into the vessels ofthe venous system, which run parallel to the arteriolarvessels and progressively form the interlobular vein,arcuate vein, interlobar vein andrenal vein, whichleaves the kidney beside the renal artery and ureter.

The Nephron Is the Functional Unitof the Kidney

Each kidney in the human contains about 1 millionnephrons, each capable of forming urine. The kidneycannot regenerate new nephrons.Therefore, with renalinjury, disease, or normal aging, there is a gradualdecrease in nephron number.After age 40, the numberof functioning nephrons usually decreases about 10per cent every 10 years; thus, at age 80, many peoplehave 40 per cent fewer functioning nephrons than theydid at age 40. This loss is not life threatening becauseadaptive changes in the remaining nephrons allowthem to excrete the proper amounts of water,electrolytes and waste products, as discussed inChapter 31.

Each nephron contains

(1) a tuft of glomerular capillariescalled the glomerulus, through which largeamounts of fluid are filtered from the blood and

(2) along tubule in which the filtered fluid is converted intourine on its way to the pelvis of the kidney (see Figure26–3).

The glomerulus contains a network of branchingand anastomosing glomerular capillaries that, comparedwith other capillaries, have high hydrostaticpressure (about 60 mm Hg).

The glomerular capillariesare covered by epithelial cells and the totalglomerulus is encased in Bowman’s capsule.

Fluidfiltered from the glomerular capillaries flows intoBowman’s capsule and then into the proximal tubule,which lies in the cortex of the kidney.

From the proximal tubule, fluid flows into the loopof Henle, which dips into the renal medulla. Each loopconsists of a descending and an ascending limb. Thewalls of the descending limb and the lower end of theascending limb are very thin and therefore are calledthe thin segment of the loop of Henle. After the ascendinglimb of the loop has returned partway back to thecortex, its wall becomes much thicker and it is referredto as the thick segment of the ascending limb.

At the end of the thick ascending limb is a shortsegment, which is actually a plaque in its wall, knownas the macula densa. As we discuss later, the maculadensa plays an important role in controlling nephronfunction.

Beyond the macula densa, fluid enters thedistal tubule, which, like the proximal tubule, lies in therenal cortex.

This is followed by the connecting tubuleand the cortical collecting tubule, which lead to the corticalcollecting duct. The initial parts of 8 to 10 corticalcollecting ducts join to form a single larger collectingduct that runs downward into the medulla andbecomes the medullary collecting duct. The collectingducts merge to form progressively larger ducts thateventually empty into the renal pelvis through the tipsof the renal papillae.

In each kidney, there are about250 of the very large collecting ducts, each of whichcollects urine from about 4000 nephrons.

Regional Differences in Nephron Structure:

Cortical andJuxtamedullary Nephrons.

Although each nephron has allthe components described earlier, there are some differences,depending on how deep the nephron lieswithin the kidney mass. Those nephrons that haveglomeruli located in the outer cortex are called corticalnephrons; they have short loops of Henle thatpenetrate only a short distance into the medulla(Figure 26–5).

About 20 to 30 per cent of the nephrons haveglomeruli that lie deep in the renal cortex near themedulla and are called juxtamedullary nephrons.These nephrons have long loops of Henle that dipdeeply into the medulla, in some cases all the way tothe tips of the renal papillae.

The vascular structures supplying the juxtamedullarynephrons also differ from those supplyingthe cortical nephrons. For the cortical nephrons, theentire tubular system is surrounded by an extensivenetwork of peritubular capillaries. For the juxtamedullarynephrons, long efferent arterioles extendfrom the glomeruli down into the outer medulla andthen divide into specialized peritubular capillariescalled vasa recta that extend downward into themedulla, lying side by side with the loops of Henle.Like the loops of Henle, the vasa recta return towardthe cortex and empty into the cortical veins. Thisspecialized network of capillaries in the medulla playsan essential role in the formation of a concentratedurine.

Urine Formation Resultsfrom Glomerular Filtration,Tubular Reabsorption,

andTubular Secretion

The rates at which different substances are excretedin the urine represent the sum of three renal processes,shown in Figure 26–8:

  1. Glomerular filtration,
  2. reabsorption of substances from the renal tubulesinto the blood and
  3. secretion of substancesfrom the blood into the renal tubules.

Expressedmathematically,

Urine formation begins when a large amount offluid that is virtually free of protein is filtered from theglomerular capillaries into Bowman’s capsule. Mostsubstances in the plasma, except for proteins, are freelyfiltered, so that their concentration in the glomerularfiltrate in Bowman’s capsule is almost the same as inthe plasma.

As filtered fluid leaves Bowman’s capsuleand passes through the tubules, it is modified by reabsorptionof water and specific solutes back into theblood or by secretion of other substances from theperitubular capillaries into the tubules.

Figure 26–9 shows the renal handling of four hypotheticalsubstances.

  • The substance shown in panel A isfreely filtered by the glomerular capillaries but isneither reabsorbed nor secreted. Therefore, its excretionrate is equal to the rate at which it was filtered.Certain waste products in the body, such as creatinine,are handled by the kidneys in this manner, allowingexcretion of essentially all that is filtered.
  • In panel B, the substance is freely filtered but is alsopartly reabsorbed from the tubules back into theblood. Therefore, the rate of urinary excretion is lessthan the rate of filtration at the glomerular capillaries.In this case, the excretion rate is calculated as the filtrationrate minus the reabsorption rate.This is typicalfor many of the electrolytes of the body.
  • In panel C, the substance is freely filtered at theglomerular capillaries but is not excreted into theurine because all the filtered substance is reabsorbedfrom the tubules back into the blood. This patternoccurs for some of the nutritional substances in theblood, such as amino acids and glucose, allowing themto be conserved in the body fluids.
  • The substance in panel D is freely filtered at theglomerular capillaries and is not reabsorbed, but additionalquantities of this substance are secreted fromthe peritubular capillary blood into the renal tubules.This pattern often occurs for organic acids and bases,permitting them to be rapidly cleared from the bloodand excreted in large amounts in the urine.The excretionrate in this case is calculated as filtration rate plustubular secretion rate.

For each substance in the plasma, a particular combinationof filtration, reabsorption and secretionoccurs. The rate at which the substance is excreted inthe urine depends on the relative rates of these threebasic renal processes.

Filtration, Reabsorption andSecretion of Different Substances

  • In general, tubular reabsorption is quantitatively moreimportant than tubular secretion in the formation ofurine, but secretion plays an important role in determiningthe amounts of potassium and hydrogen ionsand a few other substances that are excreted in theurine.
  • Most substances that must be cleared from theblood, especially the end products of metabolism suchas urea, creatinine, uric acid and urates, are poorlyreabsorbed and are therefore excreted in largeamounts in the urine.
  • Certain foreign substances anddrugs are also poorly reabsorbed but, in addition, aresecreted from the blood into the tubules, so that theirexcretion rates are high.
  • Conversely, electrolytes, suchas sodium ions, chloride ions and bicarbonate ions, arehighly reabsorbed, so that only small amounts appearin the urine.
  • Certain nutritional substances, such asamino acids and glucose, are completely reabsorbedfrom the tubules and do not appear in the urine eventhough large amounts are filtered by the glomerularcapillaries.
  • Each of the processes—glomerular filtration,tubular reabsorption and tubular secretion—is regulatedaccording to the needs of the body.For example,when there is excess sodium in the body, the rate atwhich sodium is filtered increases and a smaller fractionof the filtered sodium is reabsorbed, resulting inincreased urinary excretion of sodium.
  • For most substances, the rates of filtration and reabsorptionare extremely large relative to the rates ofexcretion.Therefore, subtle adjustments of filtration orreabsorption can lead to relatively large changes inrenal excretion. For example, an increase in glomerularfiltration rate (GFR) of only 10 per cent (from 180to 198 L/day) would raise urine volume 13-fold (from1.5 to 19.5 L/day) if tubular reabsorption remainedconstant. In reality, changes in glomerular filtrationand tubular reabsorption usually act in a coordinatedmanner to produce the necessary changes in renalexcretion.

Why Are Large Amounts of Solutes Filtered and Then Reabsorbedby the Kidneys?

One might question the wisdomof filtering such large amounts of water and solutesand then reabsorbing most of these substances.

  • Oneadvantage of a high GFR is that it allows the kidneysto rapidly remove waste products from the body thatdepend primarily on glomerular filtration for theirexcretion. Most waste products are poorly reabsorbedby the tubules and, therefore, depend on a high GFRfor effective removal from the body.
  • A second advantage of a high GFR is that it allowsall the body fluids to be filtered and processed by thekidney many times each day. Because the entireplasma volume is only about 3liters, whereas the GFRis about 180 L/day, the entire plasma can be filteredand processed about 60 times each day.This high GFRallows the kidneys to precisely and rapidly control thevolume and composition of the body fluids.

Glomerular Filtration—TheFirst Step in Urine Formation

Composition of the GlomerularFiltrate

Urine formation begins with filtration of largeamounts of fluid through the glomerular capillariesinto Bowman’s capsule. Like most capillaries, theglomerular capillaries are relatively impermeable toproteins, so that the filtered fluid (called the glomerularfiltrate) is essentially protein-free and devoid ofcellular elements, including red blood cells.The concentrations of other constituents of theglomerular filtrate, including most salts and organicmolecules, are similar to the concentrations in theplasma. Exceptions to this generalization include a fewlow-molecular-weight substances, such as calcium andfatty acids, that are not freely filtered because they arepartially bound to the plasma proteins. Almost onehalf of the plasma calcium and most of the plasma fattyacids are bound to proteins and these bound portionsare not filtered through the glomerular capillaries.