Nephrology Flashcards
Renal artery stenosis is associated with which genetic disorder?
Neurofibromatosis
What renal issues are associated with tuberous sclerosis?
Angiomyolipomas
Benign renal cysts (TSC2 > TSC1)
Renal cell carcinoma
How do you calculate serum osmolality?
Serum osmolality = (2 x Na) + glucose + urea
Renal biopsy/microscopy in IgA nephropathy vs Alports?
- Alport syndrome - variable thickness of basement membrane with splitting, thick and thin, woven basket
- IgA nephropathy - mesangial deposits and expansion (same seen in HSP as also IgA-mediated)
Which properties affect filtration of substances at the GBM?
Molecular size and electrical charge (interna and externa = charge, densa = size)
Describe cystinosis
- Lysosomal storage disease, leading to cystine accumulation
- Fanconi syndrome (prox tubular dysfunction), photophobia (corneal cystine crystals), hypothyroidism
- Later develop renal failure, diabetes (panc involvement), hepatomegaly, reduced fertility, cerebral atrophy, rickets
- Ix: slit lamp (cystine crystals), high WBC cystine levels
- Tx: electrolyte replacement, high fluid intake, thyroxine, Vit D, cysteamine (inc transport cystine), indomethacin (decr GFR)
What is the renal complication of Wilson’s disease?
Distal renal tubular acidosis which results in kidney stones.
What are the complications of APCKD?
- Hepatic cysts
- Colonic diverticula (in 80%)
- Polyuria (early manifestation)
- Renal failure (age 40-60)
What are the genes associated with congenital nephrotic syndrome, and infantile nephronophthisis?
- NPHS1 and NPHS2 - congenital nephrotic syndrome
- NPHP2 and NPHP3 - infantile nephronophthisis
What mutations are seen in Alport syndrome?
- COL4A3 - AR, early onset
- COL4A4 - AD, late onset
- COL4A5 - X-linked, early onset, most common
What are the issues seen in Alport syndrome?
- Recurrent micro and macroscopic haematuria, esp with URTI
- Sensorineural hearing loss (~age 10)
- Corneal clouding, anterior lenticonus, white or yellow spots around macula (~age 12)
- May have family history
- Can progress to proteinuria 2nd decade life and renal insufficiency in early 20’s.
- Biopsy: variable thickness of basement membrane with splitting, thick and thin portions, basket weave
- Tx: ACE- to delay progression, start when microalbuminuria
What is the issue causing IgA nephropathy?
- Abnormal glycosylation of the IgA1 molecule, meaning it is galactose deficient and therefore excess IgA is not identified by the body and degraded as usual.
- This leads to accumulation of IgA
- Body doesn’t recognise these abnormal IgA as “self” and therefore creates IgG. This binds to the IgA and causes immune complexes = type 3 hypersensitivity disorder
- These are deposited in the mesangium of the kidney.
- Activates alternative complement pathway - pro-inflammatory cytokines and macrophages released in kidney = glomerular injury
- Light microscopy: mesangial proliferation
- Immunofluorescence + electron microscopy: immune complexes in mesangium
- Same biopsy appearance in HSP (IgA nephritis)
When does IgA nephropathy present?
- During childhood with acute illness that involve mucosal lining (resp, GI) due to increased IgA production (<20% have elevated serum IgA)
- Microscopic haematuria with intermittent macroscopic haematuria
- Can develop renal failure (over decades) due to repeat injury and immune complex deposition
- Normal complement levels
- Active phase can be treated with steroids, ACE- if proteinuria
Discuss thin basement membrane disease?
- Mild mutation in COL4A3 or COL4A4 (less severe than Alport’s)
- Microscopic haematuria +/- macroscopic with URTI
- Family history, AD
- Benign familial haematuria, don’t develop proteinuria
- Annual BP and P:Cr screening, genetics for diagnosis
- Thin basement membrane on biopsy
Anterior lenticonus is pathognomonic of which syndrome?
- Alport syndrome
- Thinning of the lens capsule leads to a regular conical protrusion on the anterior aspect of the lens which is called anterior lenticonus
- Occurs in up to 30% of Alports
The macula densa is located in the?
Distal tubule
What are the classic blood test findings in acute adrenal insufficiency?
Hyponatremia, hypoglycemia, hyperkalaemia
Discuss RTA type 1 vs type 2
- RTA type II = prox renal tubular acidosis = wasting HCO3-, inability to reabsorb
- Low K+, normal Na+
- Normal urine calcium
- RTA type I = distal renal tubular acidosis = defective H+ secretion from distal tubule
- Low K+, sometimes low Na+
- Hypercalciuria
- +ve urinary anion gap (Na + K - Cl)
- AR and AD forms
Which enzymes are involved in Vitamin D metabolism in the kidney?
- 1-alpha hydroxylase converts Vitamin D to its active form and 24-alpha hydroxylase converts Vitamin D to an inactive form
- 25 hydroxylation occurs in the liver
Discuss the value of the fractional excretion of sodium
- The fractional excretion of sodium (FENa) is the most commonly used laboratory test to distinguish between pre renal AKI and ATN
- FENa <1% suggests pre renal AKI
- FENa >2% suggests ATN
- FENa between 1-2% is non-diagnostic
- FeNa = UNa x PCreat / PNa x UCreat
What is the difference between the afferent and efferent arterioles?
- Afferent arteriole Approaches the glomerulus
- Efferent arteriole Exits the glomerulus
What makes up to renal corpuscle?
- Where filtration begins
- Made up of the glomerulus and Bowman’s capsule
What is the role and anatomy of the juxtaglomerular complex?
- Involved in regulating GFR and blood pressure
- Located between the distal convoluted tubule and the afferent arteriole
- Made up of:
- macula densa cells (in DCT, sense when Na and Cl are low)
- juxtaglomerular cells (located in wall of afferent arteriole, receive messages from MD cells but also can sense low pressure in arteriole, activate RAAS)
- extraglomerular mesangial cells (help with signalling between MD and JG cells)
What are the effects of renin?
- Secreted from juxtaglomerular cells
- Increases Na reabsorption, which increases blood volume
- Causes vasoconstriction, which increases blood pressure
How do you calculate renal clearance?
- Clearance = concentration in urine x flow rate (ml/min)/ concentration in plasma
- Clearance is the sum of all the reabsorption and secretion of a substance
What are baroreceptors and where are they located?
Pressure sensors (detect stretch) located in carotid sinus, posterior wall of R atrium, aortic arch. If decr BP then baroreceptors signal to hypothalamus to secrete more ADH from posterior pituitary, to increase water retention and therefore increase BP.
What parts of the body does ADH act on?
- Distal tubule and collecting ducts of the kidney
- Once ADH binds to AVPR2 receptors, get increase of ATP-cAMP, and aquaporin-2 channels are inserted into collecting duct. Water then flows by osmosis from tubule into the interstitium and peritubular capillaries to enter systemic circulation
- Smooth muscle of arterial walls - causes contraction, to increase BP by increasing peripheral vascular resistance
Discuss the function of the ascending loop of henle
- Impermeable to water
- Losses solutes via the Na/K/Cl cotransporter and the Na/K ATP pump
= net dilution of tubular fluid with decreased osmolarity
= increased osmolarity of the interstitial fluid
Discuss the function of the descending loop of henle
- Is permeable to water and therefore can equilibrate with the interstitium
What is the corticopapillary gradient?
- Gradient created by the ascending and descending loops of Henle, with lower numbers of solutes in the cortical part of the interstitium, and higher numbers in the papillary part.
- This gradient allows fluid and solute movement in the loop of henle
- Water is secreted and then reabsorbed, solutes are reabsorbed and then secreted
What is Melnick-Fraser syndrome?
- Branchio-oto-renal syndrome (BOR)
- AD, incomplete penetrance, 1;40,000
- EYA1 + SIX1 genes
- Preauricular pits or skin tags, neck pits or fistulae, associated with renal abnormalities such as renal agenesis + chronic kidney disease
Discuss Dent disease
- X-linked recessive nephrolithiasis, mutation in the CLCN5 gene that inactivates a voltage-gated chloride transporter named CLC-5
- Polyuria, microscopic haematuria, proteinuria or kidney stones (75%)
- Some cases associated with mutations in OCRL1 gene (same as Lowe oculocerebrorenal syndrome)
Discuss the renal complications of Wilsons disease
Distal renal tubular acidosis leading to kidney stones
Discuss Goodpasture’s syndrome (anti-glomerular basement membrane disease)
- Pulmonary haemorrhage and crescentic GN
- Usually RPGN leading to renal failure
- Antibodies against type IV collagen within alveolar basement membrane and GBM - anti-GBM antibodies - activates complement system -> damage
- Light microscopy – crescentic GN
- Immunofluorescence – continuous linear deposition of IgG along GBM (against collagen)
- Serum anti-GBM Abs +ve, normal C3
- Not recurrent
- Tx: steroids, cyclophosphamide, plasmapharesis
What is IgA vasculitis?
HSP
What does the ureteric bud form?
- Ureter
- From 6 weeks this branches into calyces, renal pelvis, papillary ducts, collecting tubules
What does the mesonephric duct form?
- Evolves into a tubular structure, forms primitive mesenchyme of nephrogenic ridge, develops into metanephric blastema
- Forms renal corpuscle (glomerulus, Bowman’s capsule) and renal tubule (prox and distal tubules, loop of Henle)
Discuss the kidney function in newborn, premature and LBW babies
- Reduced nephron numbers (usually 600,000 per kidney)
- Glomerular hyperfiltration
- Risk of sclerosis, HTN, CV mortality
- Premature infants have a very high FeNa and therefore need sodium supplements
- Newborns at risk of dehydration as urine concentrating ability is low, reaches full capacity in 1st year of life
- Also have lower bicarbonate threshold, therefore plasma bicarb levels lower
Discuss GFR in the baby -> adult
- Nephrogenesis completed by 36/40
- GFR <5% of adult value
- Term GFR 25ml/min, increases by 50-100% in first week, 300% by 3m, adult range by 2y age
What renal abnormalities may be found on antenatal USS?
- Oligo or anhydramnios
- Echogenic kidneys
- Lack of corticomedullary differentiation, cysts, hydronephrosis
- Severe oligo can lead to pulmonary hypoplasia and Potter’s syndrome - major determinant of outcome, poor prognosis
How do you calculate the GFR?
- GFR = permeability of glomerular capillary wall x (hydrostatic pressure gradient - oncotic pressure gradient)
- absolute = ml/min x 1.73/surface area
- estimate = height (cm) / creatinine x 42ml/min per 1.73m2
What are the sites of major resorption in the kidney?
Proximal tubule and loop of henle. Distal tubule and collecting ducts are sites of fine-tuning
What is the role of ACE?
- Converts angiotensin I into angiotensin II. Located in endothelial cells, especially in lining of lung
- Angiotensin II stimulated hypothalamus to make more ADH
What are the main regulators of renal blood flow?
- Adrenaline in response to fight/flight -> acts on a-1 adrenergic receptors on afferent and efferent arterioles, causing vasoconstriction, leading to reduced renal blood flow
- Angiotensin II in response to low BP -> binds to angiotensin receptors along afferent and efferent arterioles, causing vasoconstriction, leading to reduced renal blood flow
- Low levels of AgII -> efferent arteriole constricts more, leading to preserved GFR
- High levels of AgII -> both afferent and efferent arteriole constrict - leading to reduced GFR
Where are ANP and BNP secreted and what is their mechanism of action?
ANP = atrial natriuretic peptide, secreted by atria BNP = brain natriuretic peptide, secreted by ventricles
Secreted in response to increase cardiac stretch, cause dilation of afferent arteriole and constriction of efferent arteriole, leading to increased GFR.
What molecules act on the kidney to increase renal blood flow?
- ANP and BNP (from heart) - cause afferent dilation and efferent constriction - inc GFR
- Prostaglandin I2 and E2 (from kidney) - cause afferent and efferent dilation - inc GFR
- Dopamine (from brain and kidneys) - cause afferent and efferent dilation - inc GFR
What are the autoregulation mechanisms of the kidney?
- Mechanisms to keep kidney blood flow constant over a range of systolic blood pressures
- Myogenic mechanism: increased stretch of arterioles due to high BP causes vasoconstriction of afferent and efferent arterioles so as to maintain constant GFR
- Juxtaglomerular apparatus - senses high Na in distal convoluted tubule, macula densa secretes adenosine, this causes afferent arteriole constriction
- Low renal perfusion leads to constriction of efferent arteriole in order to maintain GFR
Discuss the RAAS
- Angiotensinogen converted to angiotensin I by renin
- Angiotensin I converted to angiotensin II by ACE
- Angiotensin II causes vasoconstriction and increased aldosterone release from adrenal glands
- > this leads to increased Na and H20 absorption in distal tubule, and arteriolar vasoconstriction leading to inc GFR
What are causes of low-renin hypertension?
- Conn syndrome: primary hyperaldosteronism - hypertension, low K+, increased ECF volume, renin suppression. Tx: spironolactone as inhibits aldosterone
- Liddle syndrome: pseudohyperaldosteronism - causes overactivation of ENaC channels in DCT -> Na and water retention, K+ wasting, low renin and aldosterone due to suppression. Tx: amiloride as binds + inhibits ENaC channels
Discuss the renal changes in pseudohypoaldosteronism
- Elevated aldosterone, but body failure to respond
- Leads to hyperkalaemia and metabolic acidosis
- Hyponatraemia and dehydration
- Can be transient secondary to UTI in infants
- c.f. CAH with salt wasting - would have low aldosterone
Discuss pseudohyperaldosteronism
- Liddle syndrome
- Mimics hyperaldosterone but renin and aldosterone levels are normal-low
- Severe hypertension, hypokalaemia and a metabolic alkalosis are seen
- AD
- Treated with a combination of low sodium diet and potassium-sparing diuretics (e.g. amiloride)
Discuss the pathway of Vitamin D synthesis/activation
- Vit D (cholecalciferol) from UV light - hydroxylated in liver to 25 (OH) vitamin D3 (by 25-hydroxylase)
- Production of 1-25 (OH) Vit D3 (calcitriol) via renal 1-hydroxylase in kidney = most biologically active Vit D metabolite
- 24-alpha hydroxylase in kidney converts Vitamin D to an inactive form
What stimulates calcitriol (active vitamin D) production?
- Hypocalcaemia, hypophosphatemia, low growth hormone
- All cause increased renal 1 hydroxylase activity to increase calcitriol production
- Rickets associated with renal failure is due to decreased calcitriol production
What are the different types of urinary casts and their significance?
- Red cell casts - renal haematuria, glomerulonephritis
- Tubular casts - ATN
- White cell casts - pyelonephritis, ATN
What are the causes of haematuria?
- UTI
- GN - PSGN - blood, protein casts
- Lupus nephritis
- IgA nephropathy and Alport’s (isolated haematuria)
- Trauma
- Stones
- Tumours
- Cystic kidney disease
- Coagulopathy, sickle cell anaemia
- Renal vein thrombosis (neonate)
- False +ves: beetroot, rifampicin, myoglobinuria
- Fever, exercise
Discussthe albumin:creatinine ratio
- Normal <3mg/mmol
- Microalbumin 3-30
- Proteinuria >30
What is the definition of proteinuria
> 1+ protein on dipstick
Nephrotic range proteinuria is >40mg/hr/m²or a first morning urine protein/creatinine ratio >200mg/mmol (normal <20), or >3.5g/day
What are the three main causes of proteinuria?
- Due to glomerular damage (e.g.GN)
- Due to tubular damage (unable to reabsorb small proteins)
- Due to increased production of plasma proteins e.g. multiple myeloma, rhabdo, haemolysis
What can cause a false negative or false positive proteinuria on dipstick?
- False -ve with highly dilute urine
- False +ve with blood contamination, or urinary pH >7
What are causes of transient proteinuria?
- Fever, exercise, dehydration, stress, seizures, cold exposure, heart failure
When would you use renal arteriography?
- To diagnose renal artery stenosis
- Can do balloon angioplasty and embolisation
- Access via femoral artery
What are the causes of hydronephrosis?
VUR, PUJ obstruction, VUR obstruction
Discuss the severity of PUJ obstruction and management
- Usually seen on AN USS
- 5-10mm mild, 11-15mm mod, >15mm severe
- Bilateral in 10%
- Do a MAG3 scan (meat and tubes) - significant obstruction if poor drainage despite frusemide, and if <40% function on side of hydronephrosis
- 10% will have ipsilateral VUR
- Tx: pyeloplasty if worsening obstruction or hydronephrosis, or if >30mm, or complicated by UTI (noteL stent is only temporary, not a fix)
- With VUJ obstruction manage similarly but can do surgical reimplantation of ureters
Discuss duplex kidneys
- 2 ureters from 2 separate pelvicalyceal systems, usually upper pole inserts inferiorly into bladder
- Lower pole refluxes (infection and scarring)
- Upper pole obstructs (hydronephrosis, can be ectopic into urethra or vagina, bladder ureterocele with cystic dilation)
- Tx: surgical, depends on upper pole functioning and levels of VUR on MCUG
Discuss multi cystic dyplastic kidney
- Variable sized non-communicating cysts, no renal parenchyma, dysplastic atretic ureter
- May present as renal agenesis, involute over time, usually by 7yrs
- No function on MAG3/DMSA scan
- Usually unilateral, bilateral incompatible with life
- Most common cause of abdominal mass in a newborn
- Contralateral hydronephrosis in 10% (VUR, PUJ obst)
- Risks: hypertension, Wilm’s tumour
- Monitor BP, creatinine, proteinuria until age 5
- No routine removal unless large mass, increasing size of non-functioning parenchyma
Discuss horshoe kidneys
- 95% lower poles, 5% upper poles
- Isthmus at L4 below origin of IMA
- Associated with Turner’s
- Increased risk PUJ obstruction and VUR, may develop UTI, renal stones
- Increased risk Wilm’s tumour
Metabolic acidosis
- Low pH, low HCO3. Caused by:
- Bicarb loss - GI (loss in diarrhoea), renal (proximal RTA type 2, unable to absorb bicarb)
- Low H+ ion excretion - distal RTA type 1, acute + chronic renal failure - inability to excrete H+ into urine
- Inc H+ ion load - exogenous e.g. salicylate poisoning, methanol, ethylene glycol, and endogenous e.g. inborn errors metabolism, lactic acidosis (shock), DKA
Discuss metabolic alkalosis
- High pH, high HCO3. Caused by:
- Loss of H+ ions - vomiting (also causes inc HCO3 in blood), Cushing’s, hyperaldosteronism, Bartter’s, hypokalemia due to diarrhoea or diuretics. Hypokalaemia can be a cause and result of metabolic alkalosis (as K+ exchanged for H+ to improve alkalosis). Normal urinary chloride, not responsive to Cl- administration
- Gain of HCO3 ions - excessive ECF volume loss causes RAAS activation with H2O and HCO3 retention (e.g. frusemide + thiazides, severe dehydration), exogenous ingestion e.g. antacids.
- Chloride depletion - GI loss (pyloric stenosis, congenital chloride diarrhoea), frusemide, CF patients. Low urinary chloride, responsive to Cl- administration
What are the causes of a raised/normal/and low anion gap?
- Raised anion gap >20 - normochloremic. Due to accumulation of organic acids e.g. lactate, ketones, urea, alcohol abuse, toxins
- Normal anion gap - due to loss of bicarb. Hyperchloraemia compensates for low bicarb leading to normal anion gap. e.g. severe diarrhoea or Type 2 RTA, Type 1 RTA
- Low anion gap - hypoalbuminaemia, multiple myeloma
Discuss the body’s fluid composition
- 60% body is fluid
- 40% intracellular
- 20% extracellular = intravascular 5% + interstitial fluid 15%
Discuss the fluid shifts in DKA
- High glucose leads to inc intravascular osmolality
- Water shifts from intracellular to extracellular (intravascular), leads to cell shrinkage
- Cells now accumulate organic osmolytes to increase osmolality to baseline, and water shifts back to cell to restore volume
- As DKA treated, intravascular osmolality decreases, and fluid shifts back into cells
- Rapid fluid shifts with fluid replacement can lead to cerebral oedema
Discuss the body’s osmoregulation
- Small increase in extracellular osmolality sensed by hypothalamus
- Leads to increased ADH secretion into the posterior pituitary leading to water retention by insertion of aquaporin channels into DCT
- Increased water retention causes normalisation of ECF osmolality
- Large volume decrease (even if iso-osmolar) sensed by baroreceptors in aorta+carotid sinus which stimulate further ADH release
What is the normal anion gap?
- 3-11
- Made up of unmeasured anions such as organic acids and negatively charged plasma proteins such as albumin
How does the body compensate for a metabolic acidosis?
- H+ ions leave the blood and enter cells, in exchange for a K+ ion. Helps with acidosis, but results in hyperkalaemia
- However, in cases where there are excess organic acids, the H+ can enter the cells without being exchanged for K+
- Chemoreceptors in carotid arch and aorta fire when pH falls, leading to increased RR and minute ventilation, which decreases CO2
- Kidneys excrete H+ ions and reabsorb HCO3- (happens days later, and only if kidneys not initial cause of issue)
- > opposite happens in metabolic alkalosis
For each 10mmHg increase in CO2, how much can bicarb rise by?
- Acute: blood response to resp acidosis: 1mEq/L - i.e. a rise of 20mmHg CO2 leads to an increase of 2mEq/L of HCO3 = minimal changes in pH
- Chronic: kidney response to resp acidosis: 4mEq/L i.e. rise of 20mmHg CO2 leads to an increase of 8mEq/L of HCO3 = substantial changes in pH
- > opposite in respiratory alkalosis
What are causes of respiratory alkalosis?
- Overdose with salicylic (eventually leads to metabolic acidosis)
- Anxiety/panic attack
- Urea cycle disorder
- Sepsis
What are the causes of a raised anion gap metabolic acidosis?
"MUDPILES" Methanol (or formic acid) Uremia Diabetic ketoacidosis Propylene glycol Iron tablets or INH Lactic acidosis Ethylene glycol Salicylates.
How do you correct sodium in DKA?
[Na+] + (glucose -10)/3
Discuss the function of the proximal convoluted tubule
- Main site of reabsorption of Na (65%), HCO3 (85%) K (65%), Ca, Cl, Mg, lactate, amino acids, phosphate, citrate
- Na/glucose transporter - Na passive, glucose active transport against concentration gradient. Glucose then transported into capillaries passively via GLUT1 and GLUT2 (high to low conc.)
- Na/K ATPase pumps Na out of cells into interstitium (3 Na for every 2 K) - active process, requires ATP
- This leaves a low conc. of Na in cells, so Na can passively flow from tubule into cells
- Na and H20 can slip through leaky tight junctions between cells and into interstitium
- Na/H+ exchanger, allows 1 Na into cell for 1 H out of cell into tubule. This helps with HCO3 absorption as combines with H and diffuses across membrane as H2O + CO2 (via carbonic anhydrase). This then leaves cell into blood via Na/HCO3 transporter
- 50% of urea reabsorbed (passive)
- Excretion e.g. ammonia, organic acids, medications
Discuss the function of the loop of henle
- Corticopapillary gradient from low (300) to high (1200) osmolality - due to large quantities of Na and urea
- Aquaporin channels in descending limb: passive H20 transfusion out of tubule. Impermeable to solutes, therefore tubule osmol goes from 300->1200.
- Ascending limb is impermeable to water due to lack of aquaporins. Thin = squamous cells, thick = cuboidal cells
- Na and Cl channels in thin ascending limb allow passive transfusion out of tubule
- 40% of sodium reabsorption via Na/K/2Cl- cotransporter in thick ascending limb (passive) and then via NaK-ATPase (active) into interstitium and blood
- Process of countercurrent multiplication. By end of LoH, osm ~325mmol
- Loop diuretics work in ascending loop by blocking Cl- binding sites
- Inborn defect in Cl- reabsorption = Bartter syndrome
Discuss the function of the distal convoluted tubule
- Early DCT insoluble to water, passive reabsorption of Na down gradient (5% of Na, load-dependant)
- NaCl- cotransporter - moves 1 Cl (active) for every Na, Cl then passive diffusion out of cell into interstitium
- NaCa+ channels on interstitial border transporting 1 Ca+ (active) for every 1 Na (passive into cell)
- PTH causes inc NaCa+ channels, increasing reabsorption of Ca+
- Na doesn’t build up in cell as is pumped out into interstitium by NaKATPase, meaning Na can flow down gradient into cell through NaCl- and NaCa+ cotransporters
- Late DCT/collecting duct has: principal cells (has eNac - epithelial Na channel to absorb Na and K channel to excrete K, and NaK-ATPase on basolateral surface) and a-intercalated cells (has H+ATPase and H/K-ATPase which secrete H+ into tubule)
- > net movement Na and Cl- into blood, and H+ into tubule
- Aldosterone increases eNaC, ATP-dependant K+ pump, NaK-ATPase transporters, and H/K-ATPase -> net Na reabsorption and K secretion
- ADH causes aquaporin insertion into both membranes to increase H2O reabsorption
Simple action of distal convoluted tubule
- Early DCT: reabsorption of Na, Ca, Cl
- Late DCT/collecting duct: principal cells absorb Na and excrete K, a-intercalated cells secrete H+
- ADH: increases H2O reabsorption via aquaporins in principal cells
- Aldosterone: increases Na reabsorption and K+ excretion
Simple action of loop of henle
- Descending limb: absorption of water via aquaporins
- Thin ascending limb: absorption of Na and Cl- via channel proteins
- Thick ascending limb: Na, K, Cl absorption via cotransporter and channel proteins
Simple action of the proximal convoluted tubule
- Main site of reabsorption of Na (65%) (passive + NaK-ATPase), HCO3 (85%) (via NaH+ exchanger and action of carbonic anhydrase), K, Ca, Cl, Mg, glucose, lactate, amino acids, phosphate, citrate
- Excretion e.g. ammonia, organic acids, medications
What is the role of aldosterone?
Increases number of Na, K, and Na/K/ATPase channels in the DCT and collecting ducts, leading to absorption of sodium and water, and excretion of potassium
What happens to potassium levels in metabolic acidosis and metabolic alkalosis?
- Metabolic acidosis leads to hyperkalaemia due to hydrogen shift into cells, in exchange for potassium which shifts into the plasma
- Metabolic alkalosis leads to hypokalaemia, due to hydrogen shift out of cells, in exchange for potassium shifting out of the plasma into cells
What factors cause potassium shift into cells (hypokalaemia) and out of cells (hyperkalaemia)?
- Into cells: insulin, adrenaline, metabolic alkalosis
- Out of cells: exercise, burns, rhabdomyolysis, cell lysis, hyperosmolarity, metabolic acidosis