Chapter 13: Osmoregulation

Introduction
- The volume and concentration of body fluids are controlled importantly by two mechanisms:
1. Thirst
2. neurohypophyseal secretion of a potent antidiuretic hormone (ADH)
a. Which modulates urine volume and concentration.
- Even with normal renal function, obligatory renal and non-renal ("insensible") water losses would
lead to progressive negative water balance, if not for thirst.
- Even slight hyperosmolality of body fluids stimulates the hypothalamic thirst center and normally
leads to water ingestion, tending to return osmolality towards normal.
- The classic experiments of Verney (Fig. 1) demonstrated that hyperosmolality results promptly in
the secretion of a neurohypophyseal substance (ADH)
o Which results in a decrease of urine volume (and increase of urine concentration)
o Thus, changes in plasma osmolality triggers body responses (thirst, urine output) that
tend to restore the body fluid osmolality to normal.
- The renal response is dependent on the secretion of ADH
o Although osmolality is the chief factor regulating the secretion of ADH, other factors are
also significant, as will be discussed later in this lecture.
- We will also consider the renal mechanisms responsible for the changes in urine output in detail.

- The strong dependence of renal function on kidney structure was long ago inferred from the close
correlation in many species between the length of the thin loops of Henle and maximum
concentration of the urine.
- A basis for this correlation was suggested by Kuhn and coworkers, who, recognizing the
structural similarity of the nephron and its vascular supply to common engineering systems,
theorized as to how countercurrent mechanisms could produce and maintain osmotic gradients
necessary for concentration of the urine.
- In the face of considerable skepticism Kuhn et al. later presented experimental evidence for
"osmotic stratification", with progressive increase of interstitial osmolality from the cortex to the
papilla.
o Several important features of the countercurrent mechanism are now well established.
 o Despite as yet incomplete understanding, they help to explain how luminal and interstitial
osmolality profiles are created, maintained, and utilized in the regulation of urine
osmolality.
Creation of Osmolality Profiles
- Although it is natural to focus on the mechanisms directly involved in creation of osmotic
gradients, it is important to realize that there are quantitative limits on the capacities of these
systems, and so it is essential that there be mechanisms for reabsorption of large volumes of
isosmotic filtrate in the renal cortex in order to establish large gradients in the medulla.
o As you know, this occurs largely in the proximal tubules, where there are luminal and
basolateral membrane water channels ("aquaporins") that are not regulated by ADH.
o The importance of proximal tubular water reabsorption is indicated by studies in
"knockout" mice and in humans lacking the aquaporin AQP1.
The mutants absorb less than normal quantities of glomerular filtrate and are
unable to maintain water balance during dehydration, even when given an
analogue of ADH.

- Creation of osmotic gradients occurs largely in the ascending limb of the loop of Henle, where
salt is actively reabsorbed (transported from the lumen into the interstitial fluid) without transport
of water.
- Osmotic equilibration between the interstitium and the adjacent descending limb of Henle (highly
permeable to water but not to solute) results in an osmolality difference, with the osmolality of
the interstitial fluid and that in the descending limb exceeding that of the fluid in the ascending
limb by some 200 mOsm/kg at every level (Fig 2).
- The creation of a 200 mOsm/kg gradient between the lumen of the ascending limb and that of the
adjacent descending limb at each level along its length is termed the "single effect" and leads to
"countercurrent multiplication".
o The multiplication depends on countercurrent flow whereby tubular fluid moving down
the descending limb passes fluid moving upward in the adjacent, parallel ascending limb.
o An oversimplified, classical model that has been used to provide a conceptual
understanding of this mechanism is presented in Fig. 3.
 It illustrates the progressive increase in osmolality as tubular fluid flows
downward toward the hairpin loop and progressive decrease in osmolality as it
flows upward, after the turn, through the ascending limb.

- Continuous operation of this countercurrent multiplier leads to a progressive rise of interstitial

osmolality from 300 mOsm/kg at the cortex to as much as 1200 mOsm/kg at the papillary region.
- On the other hand, the osmolality in the lumen of the cortical portion of the ascending limb is
about 100 mOsm/kg.
- As we shall see later, the establishment of these gradients permits either dilution or
concentration of the urine, depending on the level of plasma ADH.
- Although our discussion and the model in Fig. 3 imply active transepithelial transport of salt
along the entire length of the ascending loop of Henle,
o active transport has only been demonstrated in the thick ascending limb.
- Countercurrent multiplication apparently involves the thin limb as well, however, as suggested
below.
- In the inner medulla, not only salt but urea also contributes to the osmolality (see below), and it
may account for up to 50% of the solute there.
o Its presence underlies another proposed, more recent model that may help to explain the
medullary solute gradient.
 o The model depends on the thick ascending limb actively reabsorbing salt in the manner
described above, but it assumes that passive processes occur in the thin loops.
o The model is based on two assumptions:
1. The descending limb is permeable to water, but not to salt or to urea to any extent
2. The ascending limb is permeable to salt and to some extent urea, but not to water.
- It is argued that as the fluid moves through the descending limb water moves into the
hyperosmotic interstitium.
- The solute concentration in the tubule lumen (mainly salt) increases until its osmolality balances
that of the interstitium, which is due to salt ions and urea.
o The result is a luminalfluid with the same osmolality but a higher salt concentration than
that in the medullary interstitium.
- When the fluid in the descending limb turns at the tip of the loop and moves into the ascending
limb, which is permeable to salt, salt moves into the inner medulla down its concentration
gradient.
o This process adds salt to the innermost regions of the medulla and is considered to play a
role in maintaining the high osmolarity there.
o It should be cautioned that while these models are useful in trying to understand the
creation and maintenance of the medullary osmotic gradient, further research is necessary
before details of this process can be fully understood.

Urea Recycling
- It has long been known that a low protein diet depresses renal concentrating ability markedly;
infusion of urea remedies this deficit within minutes.
- Although urea is a major solute of voided urine, a large fraction of the urea in the terminal inner
medullary collecting duct (IMCD) undergoes medullary recycling.
o It is absorbed from the IMCD into the interstitium, from which it moves into the lumen of
the thin ascending loop of Henle
o Then is swept through the less urea permeable thick ascending limb, distal tubule and
collecting ducts, until again it reaches the terminal IMCD.
- Urea transport across cell membranes entails diverse urea transporters, facilitated diffusion via
protein "channels", and/or by secondary active transport in association with sodium.
- With a high rate of water reabsorption from the collecting ducts during antidiuresis (high plasma
ADH), a very high concentration of urea is presented to the terminal IMCD.
o ADH enhances IMCD urea permeability, leading to rapid diffusion of urea into the
medullary interstitium.
- In antidiuresis about 50% of the interstitial osmolality is due to urea, the remaining to NaCl. In
diuresis, with low plasma ADH and low urea reabsorption from the IMCD, a significant fraction
of the filtered urea is excreted, and its contribution to the interstitial osmolality is less important.
o (Note the different interstitial osmolalities shown in Figs 4 and 5).
- Despite intensive studies on the regulation of urea and other osmotically significant solutes,
however, quantitative features of the terminal IMCD concentrating mechanism remain unclear.
- Finally, although it might be expected that renal medullary cells must shrink in the hyperosmotic
renal medulla, shrinkage is opposed by the synthesis of intracellular osmotically active solutes.

Utilization of Osmolality Profiles

- The above described mechanisms set the stage for excretion of either dilute or concentrated urine.
- As usual, water tends to flow from regions of low to regions of high osmolality, but the rate of
flow depends on the permeability of cell membranes to water.
- In the absence of ADH the collecting ducts are rather impermeable to water.
 o The luminal fluid flowing from Henles loop is diluted (120 mOsm/kg), but water is
unable to cross the tubules, and continuing salt reabsorption in the distal tubules and
collecting ducts reduce the lumenal fluid osmolality even further.
o The osmolality of the voided urine may be as low as 50 mOsm/kg (Fig. 4)

- On the other hand, in the presence of high blood concentrations of ADH, the late distal tubules
and collecting ducts become highly permeable to water and permit equilibration of the luminal
fluid with the increasingly hyperosmotic interstitium in the course of descent through the terminal
nephron (Fig. 5).
o Therefore, the level of plasma ADH determines the volume and concentration of the
urine. When plasma ADH is low or absent, a large volume (about 10% of the GFR or 18
L) of diluted (50-60 mOsm/kg) urine is excreted.
o In the presence of maximal plasma levels of ADH, a small volume (near 0.5 L) of
concentrated (1,200 mOsm/kg) urine is excreted.
o This volume of urine is known as the obligatory water loss (required for the excretion of
waste products).
o It contributes to dehydration when a person is deprived of water intake.
o Normally, plasma ADH levels, and therefore urine volume and osmolality, are between
these two extremes.
- We will discuss later in this lecture the mechanisms that regulate ADH secretion.
- The mechanism of action of antidiuretic hormone on cell water permeability has been intensively
studied.
o Binding of ADH to a basolateral receptor activates adenylate cyclase via a guanine
nucleotide binding protein, with formation of cyclic AMP and phosphorylation of
membrane proteins that leads to incorporation of AQP2 into collecting duct luminal
membranes (Fig. 6).
- In addition to its enhancement of cell water permeability, ADH influences urine osmolality and
volume by:
o Stimulating thick ascending limb salt transport
o Depressing vasa recta blood flow (see below)
o Enhancing inner medullary collecting duct urea transport
- Stimulation of active NaCl reabsorption in the thick ascending limb raises osmolality in the
interstitium, facilitating water reabsorption from the adjacent collecting ducts.
- Depression of vasa recta blood flow reduces washout of interstitial solute and protects osmotic
stratification.
- Enhanced urea permeability of the terminal medullary collecting duct contributes importantly to
interstitial osmolality, which reaches some 1200 mOsm/kg during antidiuresis, and
is associated with enhanced water reabsorption.
Maintenance of Interstitial Osmolality Profile
- Blood flow through the medulla tends to dissipate the interstitial osmolality gradients.
o However, the tendency for dissipation of osmotic stratification by diffusion and/or bulk
flow in efferent blood vessels is counteracted by passive countercurrent exchange of
solutes and water between the closely apposed descending and ascending vasa recta (Fig.
7).
- Recall that the vasa recta form straight loops reaching the inner medulla.
- Because of the high permeability of these capillaries to water and small solutes, the plasma in the
descending vasa recta gets concentrated as it flows into the medulla.
o However, while flowing through the ascending portion, where solute concentration in the
interstitium decreases progressively at higher levels in the medulla, the plasma is diluted
as solutes leave and water enters the vasa recta.
o This passive countercurrent exchange thereby minimizes, although does not abolish,
solute washout
Regulation of ADH Secretion
- Dilution of body fluids (decreased osmolality) inhibits ADH secretion, whereas increased plasma
osmolality or significant volume depletion of body fluids lead to increased secretion of ADH.
- ADH is secreted by certain hypothalamic neurons whose axons terminate in the posterior
pituitary.
o They receive inputs from neighbor neurons that function as osmoreceptors (Fig. 8).
o These osmoreceptors are exquisitely sensitive to the plasma osmolality, increasing their
firing rate when the osmolality increases and stimulating ADH secretion.
- Conversely, when plasma osmolality is low, the osmoreceptors' rate of firing decreases, and ADH
secretion is reduced (Fig 9, left).
- The ADH secreting neurons also receive inhibitory inputs from baroreceptors and
cardiopulmonary receptors (Fig. 8). With extreme depletion of both salt and water, or in disease
states in which volume receptors and baroreceptors are under-stimulated (i.e., with low ECV),
ADH secretion is enhanced (Fig 9, right) and leads to renal water reabsorption.
o Note that the baroreceptor response requires a volume depletion of more than 10% (Fig.
9, right).
o Under this condition, ADH secretion is stimulated to such an extent that it overrides the
osmoreceptor regulation and can lead to a lowering of osmolality well below normal.
- Other factors are also important in modulating ADH secretion.
- With significant alterations of salt and water balance angiotensin II will stimulate and natriuretic
hormone will inhibit ADH secretion. Alcohol and certain drugs will also alter the normal pattern.
- Finally, whereas ADH is a prime factor in short-term regulation, other as yet incompletely
characterized factors contribute importantly to long-term regulation of the concentrating
mechanism, since extended periods of dehydration produce substantially higher urine osmolality
than that following administration of a long-acting preparation of ADH