Renal Hemodyn Lec 1-HX
description
Transcript of Renal Hemodyn Lec 1-HX
Regulation of Renal Hemodynamics and GFR
L. Gabriel Navar, Ph.D.Department of Physiology
Hypertension and Renal Center of Excellence
Tulane University Medical SchoolNew Orleans, LA
Performance Objectives1. Define and calculate the renal fraction of the cardiac output and the factors that influence it.
2. Know the average values for renal blood flow (RBF) and glomerular filtration rate (GFR) in adult humans. Compare blood flow and oxygen consumption in kidneys to that of skeletal muscle.
3. Define and calculate the filtration fraction.
4. Identify the extrinsic and intrinsic factors that regulate renal blood flow and renal vascular resistance. Predict changes in RBF and GFR caused by increases in sympathetic nerve activity and increases in circulating epinephrine.
5. Identify the major sites of renal vascular resistance and describe the hydrostatic pressure profile along the renal vasculature.
6. Describe the roles of hydrostatic and colloid osmotic pressures in regulating glomerular filtration rate. Describe the filtration barriers in the glomerular membrane. How are proteins and macromolecules restricted from passing into the tubular fluid?
7. Given the glomerular and Bowman’s space hydrostatic and colloid osmotic pressures, be able to calculate the net filtration force for glomerular filtration. Define the glomerular filtration coefficient and explain its role in determining GFR.
8. Define the phenomenon of renal autoregulation and describe the roles of tubuloglomerular feedback mechanism and the myogenic mechanism.
9. Predict the changes in RBF and GFR caused by increased angiotensin II levels, increased prostaglandin E2 formation, increases in nitric oxide formation and increases in renal sympathetic nerve activity.
10. Describe the changes in tubular reabsorption associated with changes in hydrostatic and colloid osmotic pressure in the peritubular capillaries.
11. Review and be prepared to discuss questions on p. 46.
Kidney disease is a national epidemic, affecting about 20 million Americans, or one out of every nine adults. There is a World Kidney Day every year. This year, it is on Mar. 8.
A National Surge in Kidney Disease
The Washington Post, August 23, 2005
Kidney Disease in the United States:Living on the Kidney Belt
Good cholesterol, bad cholesterol and blood sugar levels are familiar to most African Americans at risk, but kidney disease is off the radar screen, a new study reports.
The rate of kidney failure for African Americans is four times higher than among Caucasians and one reason for this is that they are not aware when they have earlier stages of kidney disease, at a time treatment could prevent the damage from progressing to the point when dialysis or kidney transplant is necessary. The problem appears to be specific for kidney disease, since most African Americans who had diabetes, hypertension, or high cholesterol knew so.
Kidney Disease in African Americans Goes Undetected Until the Latest Stages
Outline of Presentation
1. Relationship of renal physiology and hemodynamics to previous sections on cardiovascular function and body fluid regulation
2. Issues of clinical relevance
3. Structural functional relationships and review anatomy and histology and overall anatomy
4. Pressure profiles along the nephrovascular unit and glomerular and peritubular capillary dynamics
5. Restriction of macromolecular permeability and role of charge and size selectivity
6. Intrinsic versus extrinsic mechanisms
7. Effects of sympathetic stimulation
The kidney presents in the highest degree the phenomenon of sensibility, the power of reacting to various stimuli in a direction which is appropriate for the survival of the organism; a power of adaptation which almost gives one the idea that its component parts must be endowed with intelligence.
E. H. Starling
Homer Smith
Superficially, it might be said that the function of the kidneys is to make urine; but in a more considered view one can say that the kidneys make the stuff of philosophy itself.
Salt and Water Homeostasis
IntakeSkin and
RespiratoryLosses
FecalLoss
UrinaryExcretion
Net Balance of Salt and Water
EXTRACELLULAR FLUID VOLUME
InterstitialFluid Volume
BloodVolume
CardiacOutput
ArterialPressure
RenalExcretion
of Saltand Water
PlasmaCompositional
Alterations
NervousSystem
HormoneSystems
+ - - -
Nephrovascular Unit
From Boron and Boulpaep
Magic of the Kidney
Kidneys: Arteriolar Network
Renal Fraction
Cardiac Output = 6 liters/min
Renal Blood Flow = 1.2 liters/min
Picture from: http://www.tuberose.com/Kidneys.html
Renal Fraction
RBF
CO
1.2 L/MIN
6 L/MIN
= 0.2 or 20%
Renal Blood Flow
By: Kidney Weight
Total Renal Blood Flow = 1200 ML/MIN
Weight of Both Kidneys = 300 Grams (70 kg person)
RBF = = 4 ML/MIN-GM1200300
Oxygen Consumption (Per 100 ML Blood)
20 ML O2
18.6 ML O2
A-V Difference = AO2 – VO2
Total Oxygen Consumption
Total RBF O2 Consumed100 ML Blood
X
1200 ML/MIN X 1.4 ML = 16.8 ML/MIN
Total Oxygen Consumption
I Mimura & M Nangaku. Nat Rev Nephrol 6:667-678, 2010
Arterial – Venous Oxygen Shunt Between Artery and Vein
AVOxygenShunt
I Mimura & M Nangaku. Nat Rev Nephrol 6:667-678, 2010
Arterial – Venous Oxygen Shunt
Distribution of Glomerular & Postglomerular Blood Flow
Postglomerular Flow% Total
Preglomerular Flow% Total
Renal Vascular and Tubular Network
Renal Microvasculature
Glomerular Capillary
Endothelial Fenestrations
Glomerular Podocytes
Glomerulus Between Afferent and Efferent Arterioles
Blood Gel BM Bowman’sSpace
Jv
From: Ohlson et alAJP: Renal 280:F396, 2001
Glomerular Charge and Size Selectivity Preventing Leakage of Proteins into Tubules
Effects of Charge on Glomerular Permeability
Glomerular Membrane
P Garg and T Rabelink. ACKD 18:233‐242, 2011
Passage of Macromolecules Across Glomerular Capillaries
Hydrostatic Pressure Profile Along the Kidney
mmHg
Filtration: PG > πG
Reabsorption: PC < πCπif < πC
PRA
PG
PC
Arteries AfferentArteriole
EfferentArteriole
GlomerularCapillaries
PeritubularCapillaries Veins
100
80
60
40
20
RA RE
Navar, LG, 1998
Hydrostatic Pressures
60 20
Net Hydrostatic Pressure= 40mmHg
Colloid Osmotic Pressures
-31
Net Pressure= -31mmHg
037
25
Effective Filtration Pressure
-31Hydrostatic Colloid
Osmotic Net
40
9
Effective filtration pressure = HP – COP = 40 – 31 = 9 mmHg
Hydrostatic Pressure Profile Along the Kidney
RE = PG – PC/ RBF - GFR
Normal Human Values(Both kidneys)
RBF = 1200 ml/minRPF = 685 ml/minGFR = 130 ml/min
FF = GFR/RPF = 0.19
mmHg PRA
PG
PC
Arteries AfferentArteriole
EfferentArteriole
GlomerularCapillaries
PeritubularCapillaries Veins
RA = (100 – 54)/1200 RE = (54 – 18)/(1200 – 130)
100
80
60
40
20
RA = PRA – PG/ RBF
Filtration
Reabsorption
Navar, LG, 1998
Glomerular and Peritubular Capillary Dynamics
Possible Mechanisms Mediating Decreases in Filtered Load or Enhancement of Peritubular Reabsorption
Preglomerular Constriction
glomerular pressure
blood flow and GFR
peritubular and renal interstitial pressure
Preglomerular and Efferent Constriction
No change or increases in glomerular pressure
glomerular colloid osmotic pressure
Less % change in GFR than in RBF
peritubular and renal interstitial pressure
Decreases in Filtration Coefficient
in GFR
No change or slight glomerular pressure
Less change in RBF than GFR
Afferent Arteriole and Renal Corpuscle
Ca2+
Ca2+-Cal
Ca2+Phosphoinositides
cAMP
cAMP
PhosphorylatedMLCK
(inactive)
Calmodulin
Myosin LightChain Kinase
(MLCK)
MyosinLight Chain
(MLC)
Actin
DAG + IP3
PKC
VOC
PKA
S R
Ca2+
ROC
PLC Gs
Ad Cy
R+
-
Active MLCK
PhosphorylatedMLC
TensionDevelopment
Ca2+
Ca2+
Smooth Muscle Cell
Endothelial Influences on Vascular Smooth Muscle
NOEDHF
PGI2
TXA2EDCF
PGF2
ET
Smooth Muscle Cell
Endothelial Cell
Ang II
Ang I
ACE
CGRP
Insulin
Histamine
VasopressinThrombin
SerotoninBradykinin
Acetylcholine
ATP/ADPTGF1
Leukotrienes
ShearStress
CalciumIonophore(A23187)
PlateletActivating
Factor
Substance P
Outline of Presentation
8. Renal autoregulationa. Myogenic and tubuloglomerular b. Feedback mechanisms
9. Other intrinsic regulationsa. Endothelial factorsb. Renin-angiotensin system c. Prostaglandins
10. Presentation of clearance concepts and filtered loads11. Measurement of GFR12. Measurements of renal plasma flow and use of PAH
clearance13. Examples of clearance problems14. Assignment of Clearance Problems
Arterial Pressure
Blood Composition
Neural Inputs
Hormonal Signalling
IntrarenalMechanisms
VenousEffluent
Urine
Lymph
Change in VolumeChange in CompositionRelease of Hormones
Waste ProductsExcess ElectrolytesFree Water Formation
Return Proteins to Circulation
Hormones
“Inputs and Outputs” of the Kidney
Hydrostatic Pressure Predominates Filtration
Colloid Osmotic Pressure Predominates Reabsorption
Glomerular and Peritubular Systems
The Tubular Transport Processes
Control of Renal Blood Flow & Renal Vascular Resistance
Arterial Pressure
Renal Blood Flow
Renal Nerves
Hormones Plasma
Composition
Intrinsic Control Mechanisms (autoregulation, macula densa, paracrine factors)
Art. PRVR
Renal Vascular
Resistance
Ca2+
Ca2+-Cal
Ca2+Phosphoinositides
cAMP
cAMP
PhosphorylatedMLCK
(inactive)
Calmodulin
Myosin LightChain Kinase
(MLCK)
MyosinLight Chain
(MLC)
Actin
DAG + IP3
PKC
VOC
PKA
S R
Ca2+
ROC
PLC Gs
Ad Cy
R+
-
Active MLCK
PhosphorylatedMLC
TensionDevelopment
Ca2+
Ca2+
Smooth Muscle Cell
Endothelial Influences on Vascular Smooth Muscle
NOEDHF
PGI2
TXA2EDCF
PGF2
ET
Smooth Muscle Cell
Endothelial Cell
Ang II
Ang I
ACE
CGRP
Insulin
Histamine
VasopressinThrombin
SerotoninBradykinin
Acetylcholine
ATP/ADPTGF1
Leukotrienes
ShearStress
CalciumIonophore(A23187)
PlateletActivating
Factor
Substance P
Hormones Affecting Renal Hemodynamics
1.Vasoconstricting Hormones:A. EpinephrineB. Angiotensin
2.Vasodilator Hormones:A. ProstaglandinsB. BradykininC. Atrial Natriuretic Peptide
Increased Nerve Activity
Effects of Renal Nerve Stimulation
Segm
ente
d Va
scul
ar
Res
ista
nce
% C
ontr
ol
Glo
mer
ular
Fi
ltrat
ion
Rat
ePl
asm
a Fl
ow%
Con
trol
Preglomerular
Efferent
Frequency of Renal Nerve Stimulation (Hz)
Hemorrhage Induced Renal
Nerve Activation
ANP Responses
Renal Hemodynamics
INTRINSIC
EXTRINSIC
Control Mechanism:AutoregulationTubuloglomerular FeedbackParacrine Factors
Control Mechanism:Sympathetic NervesHormonesOther
Renal Blood Flow Versus Pressure
RENAL ARTERIAL PRESSURE, mmHg
RE
NA
L B
LOO
D F
LOW
ml/m
in. g
0 50 150100 200
5
4
3
2
1
0
Normal Range
Circadian Rhythms in Blood Pressure in Normal Subjects and Hypertensive Patients
Normotensive Patients(N=6)
Hypertensive Patients(N=20)
Blood Pressure(mmHg)
Blood Pressure(mmHg)
Time of Day (h) Time of Day (h)
Renal Autoregulatory Responses to Changes in RAP
RA
RENAL ARTERIAL PRESSURE, mmHg RENAL ARTERIAL PRESSURE, mmHgR
EN
AL
BLO
OD
FLO
Wm
l/min
. g
VAS
CU
LAR
RE
SIS
TAN
CE
mm
Hg.
min
. g/m
l
20
15
10
5
00 50 150100 200 0 50 150100 200
5
43
2
1
0
RE
Myogenic Responses
Po Pi
R
Tension(T)
T = (Pi - Po) R
Initial Tension IncreaseTension Decline Upon Constriction
Gain =
(Pc - P) . RcP . (R - Rc)
=
L n 8P R4
Flow =
Renal Autoregulatory Responses to Changes in RAP
Renal Arterial Pressure (mmHg)
Ren
al B
lood
Flo
wm
l/min
/gVa
scul
ar R
esis
tanc
em
mH
g/m
in/g
/ml
Glo
mer
ular
Filt
ratio
nR
ate,
ml/m
in/g
Pres
sure
mm
Hg
Proximal Tubule
Distal Tubule
Collection or Pressure Pipette
Wax Blocking Pipette
Perfusion Pipette
Micropuncture and Microperfusion
Macula Densa – Vascular Pole
Components of the Tubuloglomerular Feedback Mechanism
ArterialPressure Plasma Colloid
Osmotic Pressure
Proximal Tubuleand Loop of Henle
Reabsorption
Afferent ArteriolePreglomerularResistance
Macula Densa:a) Sensor Mechanismb) Transmitter
GlomerularPressure andPlasma Flow
GlomerularFiltration
Rate
Early Distal Tubule:Flow Related ChangesOsm and NaCl Conc.
GlomerulotubularBalance
Proximal toDistal Tubule
Flow
Intact and Interrupted TGF
Tubuloglomerular Feedback Mechanism
PerfusionPipette
CollectionPipette
WaxBlockingPipette
DistalTubule
MaculaDensa
ProximalTubule
Distal Nephron Delivery
Sing
le N
ephr
onG
FR
Ca++ Channel BlockerAng II BlockadeCytochrome P450 Blockade NO PGI2
Sensitivity:
Normal
Sensitivity: Ang IINOS Blockade Thromboxane HETE
Autoregulation and TGF
HemodynamicInputs
TubularMetabolicFunction
Renal Autoregulation
Physiological:
Pathological:
•Capability to maintain hemodynamic function in balance with metabolic capabilities of tubules.
maintain RBF and GFR in face of extrinsic perturbations
alter RBF and GFR in response to body fluid volume and functional demands
•Reserve vasodilatory capability following pathological insults.
glomerular pressure of all nephrons to compensate for Kf such as in acute renal failure and glomerulonephritis
hyperfiltration in remaining nephrons after loss of functional nephrons
Receptor PLA2
Arachidonic Acid
COOH
EETS20-HETE
Epoxygenase
Hydroxylase
PGE2
Leukotrienes 12-HETE
PGI2TXA2
TXA2 SynthaseIsomerases
ProstacyclinSynthase
PGH2
HPETE
O
CH2-O-C-R
AA-CH
CH2-PO4-R'
Lipoxygenase
Cyclooxygenase
Cytochrome P450
RenalVasodilation Renal
Vasoconstriction
RenalVasoconstriction
RenalVasodilation
RenalVasoconstriction
RenalVasoconstriction
Renal Actions of Arachidonic Acid Metabolites
Renal Hemodynamic Responses to NSAIDs in Sodium Repleted and Depleted Conditions
Na+ Replete
Na+ Deplete
Na+ Replete
Na+ Deplete
Control NSAID
Ren
al P
lasm
a Fl
owm
l/min
GFR
ml/m
in
Renin Angiotensin System
NaClIntake
ArterialPressure
ECFVVolume
StressTrauma
Macula Densa Baroreceptors
Sympathetic Nervous System
ReninRelease
Juxtaglomerular Cells
Cytosolic Ca++
cAMP
Diuretics
LoopDiuretics
Angiotensinogen
ReninInhibitors
Angiotensin IAngiotensinConverting
Enzyme
ACEInhibitors
ReceptorBlockersAngiotensinases
Receptor Binding &Biological Actions
Metabolites
Angiotensin II
Renin
PGE2
Juxtaglomerular Apparatus
Effects of Angiotensin II
●Tubuloglomerular Feedback and Autoregulation:►alters filtered load to maintain balance with metabolically determined tubular reabsorptive processes►maintains GFR and RBF during fluctuations in arterial pressure
●Renin –Angiotensin System:►alters levels of hemodynamic function in accord with status of sodium balance►stimulates sodium reabsorption►increases sensitivity of TGF mechanism►reduces RBF and GFR
●Prostaglandins:►complex system with capability to activate vasoconstrictor and vasodilator systems►partially counteract actions of Ang II
●Neural and Adrenergic Systems:►integration with overall need to maintain sodium balance►responds immediately to emergency conditions
Renal Hemodynamic Control Mechanisms