BCHE4030 Clinical Biochemistry

Part 4: Electrolytes and

Water Balance / Disorders

江紹佳 榮休教授
⾹港中⽂⼤學 ⽣命科學學院
Prof. SK Kong (Emeritus Professor)
Programme of Biochemistry, School of Life Sciences
The Chinese University of Hong Kong
Office: MMWB 622B, Tel: 3943-6799
E-mail: [email protected]

118
 Kidney & Nephrons

• Every 30 minutes, our kidneys filter all the blood in the body.
• 1-2.5 M Nephrons/Kidney - Functional units of the kidney

Kidney Functions:
1) Regulation of Water & Electrolyte Balance
2) Regulation of Systemic BP & Extracellular Fluid Volume
3) Excretion of Metabolic Wastes & Foreign Substances
4) Regulation of RBC Production
5) Regulation of Vit D Production & Ca2+ & Phosphate Balance
6) Gluconeogenesis
7) Regulation of Acid-base (A-B) Balance

119
Matching (e.g. 1Aa) 2 13
1 4
A) Afferent Arteriole
B) Collecting Duct
C) Distal Tubule 8
D) Glomerulus
E) Bowman’s Capsule 11
3
F) Ascending Thick Limb
G) Descending Thin Limb 12
H) Proximal Convoluted Tubule
5
11K 12L
I) Loop of Henle 9B 10J
J) Vasa Recta
6
7If 8Ce
K) Cortex 5Gc 6Fd
L) Medulla 7 10 9 3E 4Hb
M) Efferent Arteriole 1A 2Da 13M

a Filters fluid from blood into Bowman capsule; prevents passage of blood cells and proteins
b Transports 2/3 of filtered H2O & electrolytes & all of the filtered HCO3-, glucose, amino acids, & vitamins from filtrate to ISF
c Transports water; delivers a concentrated filtrate to ascending loop of Henle
d Actively transports Na+, K+, Cl− to produce a hypoosmotic filtrate & a high ISF osmolality
e Transports Na+, Cl−, water, urea; responsive to aldosterone; site of macula densa regulation of GFR; secretes H+ & K+
f Passively transports water under the influence of ADH; secretes H+ & K+
http://blog.lib.umn.edu/trite001/studyinghumananatomyandphysiology/2008/04/ 120
 Some More Important Parts of Nephron
Macula Densa Distal Convoluted
A group of epithelial cells in Tubule (DCT)
contact with glomerulus à Between the Macula Densa
NaCl Sensing à Modulate & Collecting Duct
the Glomerular Filtration Rate

Collecting Duct
(CD)

Thin Descending Thick Ascending

Limb of LoH Limb of LoH 121
DCT & Collecting Duct: 2 Cell Types, 2 Functions

K+ Channel: On the Basolateral Side

1) Principal Cells:
Na+ Reabsorption, K+ Secretion
& H2O Reabsorption, Under the
ADH & Aldosterone Control

2) a-Intercalated Cells:
A-B Transport

http://what-when-how.com/acp-medicine/disorders-of-acid-base-and-potassium-balance-part-1/ 122
 Different Permeabilities in Descending Thin Limb & Ascending Thick Limb of the LoH

• Q: How do the kidneys vary the urine concentrations?

• Descending & Ascending limbs of the LoH: Different Permeabilities
• Normal blood Osmolality: 286 mOsM/Kg H2O
• Urine’s Osmolality: ~1200 mOsM/Kg H2O (4X > ECF)
• Blood in Vasa Recta à Counter Current Flow à H2O Reabsorption

Less concentrated

Vasa Recta
2

1 Ascending Thick Limb of LoH:

3) NaCl out thro’ Paracellular Pathway
4) No H2O Channels à
Descending Thin Limb of LoH: Impermeable to H2O
1) H2O leaves thro’ H2O Channel Osmolarity becomes
2) No Ion leaves trapped in the medulla (3)+(4): 1200à300 mOsM/Kg H2O

(1)+(2)à1200 mOsM/Kg H2O

Loops of Henle (LoH) Highly Concentrated 123
 Na+ ReAbsorption in Ascending LoH Limb by
Para- & Trans-cellular Pathway
10 Not so
Tight
Junction 9
11

1) Apical (Lumen), Basolaterial (ISF) 4 3

2) H2O leaves thro’ H2O Channels 9 8
2 10
(Aquaporin1 (AQP1)) in Descending Limb.
3) Na+/K+-ATPase found in the Basolateral side only 6
7
4) Na+ Re-absorbed by Na+/K+-ATPase & 2o Active Transport
in Ascending Limb. 5 5 1a
5) Leak K+ Channels (on both sides) open up all the time. Apical
Basolateral
1b (Lumen)
6) Cl- compensation à Electro-Neutrality. (ISF)
7) NKCC Co-transporter (Apical side) transports ions from the lumen into tubular cells, Not so Tight Junction
+ o
using the Potential Energy from the [Na ] Gradient à 2 Active Transport.
8) Also, Na+ à Tubular cells by Na+/H+ Antiporter, using the [Na+] gradient.
9) With channels & transporters’ activities, +ve charge (+8 to +25 mV) in lumen à Forces Cations à ISF
via the Paracellular Pathway (PP ~50% Na+ Uptake; Transcellular Pathway: ~50%).
10) PP involves ‘Not so Tight junctions’ ≈ Ion channels (e.g. size, charge selectivity) à Ion leaky, but watertight.
11) The ascending limb of LOH is impermeable to H2O à Filtrate in Lumen becomes diluted (1200à300).
124
 Regulation of Water Balance
áECF Osmolality à Thirsty sensed by 2 Sensors:
(A1) OsmoReceptors in Hypothalamus (Sensitivity: 1% Change); A1
(A2) Dehydration à âBlood Vol (Change >10% (> 500 mL)) à
Sensed by Blood Vol R (Stretch R in Heart Atria; Baroreceptor in Aorta)

Q&A: Change in 1% in Osmolality = ? g NaCl A2

(ECF = 15L, 286 mOsmol/kg H2O, NaCl MW=58)
B
1.24g of NaCl

Next (B): Pituitary GlandàAnti-diuretic Hormone (ADH)

Diuretic: áUrine Output
Action of ADH
Human: 8-Arginine Vasopressin (AVP) Peptide Hormone
Pig: 8-Lysine Vasopressin (LVP) C

(C): ADH à Aquaporin* (4 Types in Humans) Insertion Homeostasis

in Collecting Duct à H2O Reabsorption
*Aquaporin: Found by Peter Agre in 1992 (Nobel Prize in Chem, 2003). 125
 ADH (aka Vasopressin) – Mechanism – AQP2
1

3
4
Lumen AQP3
AQP2 6
7
AQP4 Vasa
5 Recta

8
1) Epithelial Cells in CD
2) Tight Junctions on the Apical Side
3) Thirsty à ADH à V2 Receptor à cAMP à AQP2 to the Apical side (Lumen) (4)
à Phosphorylation à H2O Reabsorption à Action ends à Channels back by Endocytosis (5)
6) H2O leave the Basolateral side thro’ AQP3 & AQP4 (AQP3 & AQP4 Not Controlled by ADH)
7) H2O back to the blood thro’ Counter Current Mechanism with Blood Vessel Vasa Recta
8) ADH ½ Life: ~30 min: With ADH: Urine 1200 mOsM/Kg; Without ADH: Urine 100 mOsM/Kg 126
 Progesterone
Experience in Our Daily Life
Estrogen
1 2

Ovulation

Cytoplasmic
Receptors Menses

Vitamins and Hormones, 2020, 112:243-264

3
1) Estradiol à Blocks AQP2 Expression à áUrine Output
2) Before Menstruation: âEstradiol à áAQP2 à áH2O Reabsorption
à Swelling à
3) Premenstrual Syndrome (PMS) Am J Physiol Renal Physiol, 2015, 309:F305–7

• Small Cell Lung Carcinoma à áADH à áH2O Reabsorption à

Plasma [Na+] < Normal
127
 Oxytocin (催產素 aka Love Hormone)
• Similar to ADH (Peptide Hormone, 9 aa with -S-S-)
• Baby Breast-feeding à Nipples Stimulation à Release Oxytocin à áPair-bonding & Trust Building
• Sex Intercourse à Release Oxytocin à áTrust/Bonding, âAnxiety, Promote Sleep, Romantic Attachment
• Oxytocin Spray à áPositive Relationship à áGroup Dynamics

4 5
3

2
6 7 8 9
1
Oxytocin Spray
from on-line shop

• Pregnancy à Oxytocin à áTotal Body H2O à Wt Gain / Breast Tenderness (Adaptation for Baby!)
• Oxytocin à Cervical Dilation & Contraction à Childbirth [Under a Positive Feedback Control]
• IV injection of Oxytocin (1/2 life in the blood: 3 min; denatured by Liver) (Nasal Spray: 2h) à Birth Induction
• Oxytocins cross the placenta à Silence the Brain à âHypoxic Damage during Childbirth (Sci, 2006, 314:1788–92)
• In the last 3 months of pregnancy: Placenta à synthesizes Vasopressinase à Inactivates Oxytocin
(also ADH) à Polyuria (áUrine Volume & Frequency)
Q: Physiological function of Vasopressinase? 128
 Diabetes Insipidus (尿崩症)
• DI: A disorder unable to concentrate urine.
• DI patient à 12 L of Urine/day (Bladder Volume: ~500 mL)
• Water Loss à Excess Na+ Accumulation. 大水缸阿姨 患了尿崩症
每天要喝七升水，上廁所30多次，晚上
• 2 Types of Disorders: 沒睡過一個整覺。生活質量嚴重下降，
稍微遠一點的地方都不敢去，就怕沒廁
A) Central or Neurogenic DI: 所，沒水喝。
A1) Head Trauma/Injury à Lack of ADH https://kknews.cc/health/arxybvx.html
A2) Vasopressinase in the Blood à ADH destroyed (Pregnancy DI)
B) Nephrogenic DI (Next slide):

• Treatment for Bedwetting: Hormone Replacement Therapy:

Desmopressin (A Synthetic ADH/Vasopressin, Trade name: dDAVP)

D-form amino acid 129

 Diabetes Insipidus (尿崩症)
B) Nephrogenic DI (NDI): No response to ADH à Abundant diluted urine
B1) X-linked V2 Receptor Gene Mutation
B2) X-linked AQP2 Gene Mutation
B3) Li+ Side Effects for Neuro-disorder Treatment (e.g. mania (躁狂症), depression, alcoholism)
• Na+ channels fail to distinguish Li+ from Na+ à Li+ into epithelial cells in collecting duct à
• Na+/K+-ATPase cannot pump out Li+ à Li+ blocks cAMP Pathway à No H2O reabsorption.
• Treatment: Discontinue Li+ therapy; Use Amiloride to block Na+ channel for Li+ influx

ADH 1

XX
X
2
AQP3/4 H2O

Nat Rev Nephrol, 2015, 11:576-88. http://ajpcell.physiology.org/content/307/7/C595 130

 Urea Concentrates Your Urine
• áProtein diet à áUrea (~4 mmol urea/g protein) (Uncharged, áMembrane Permeability Coeff (Hand cream)).
• á[Urea] à Toxic, but useful in small amounts à Urine Concentration.
• Urea Recycling in inner medulla à áOsmotic Gradient à H2O Reabsorption.
• Low-protein diet à âUrea à Unable to conserve water in the kidney.
• ADH à cAMP à Urea Transporter in CD à áUrea Permeability à Urea Recycling
(Tall Epithelial Cells in Thick Ascending Limb Impermeable to urea)

1200
PT: Proximal tubule Urea
DL: Descending limb (loop of Henle)
900 AL: Ascending limb (loop of Henle) 600

Osmolality
CCD: Cortical collecting duct
IMCD: inner medullar collecting duct
600

300
Electrolytes
600
PT: Proximal tubule
DL: Descending limb (loop of Henle) PT DL AL CCD IMCD
AL: Ascending limb (loop of Henle)
CCD: Cortical collecting duct 素食父母連續四月餵 <植物奶>
[Number: mOsmol/L] IMCD: inner medullar collecting duct
七個月大BB 營養不良脫水亡 19/5/2017131
 Key Concepts

1. In what part of the nephron does the regulated water reabsorption occur?
2. Which parts of the nephron create the hypertonic ISF in the medulla?
3. Which part of the LoH (descending limb or ascending limb) is relatively impermeable to water
4. Vasopressin increases the number of _______ on the _______ the membrane of cells in the _______.
5. Vasopressin is secreted from the _________.
6. A deficiency of vasopressin causes _________.
7. The drug for neuro-disorder therapy which causes acquired nephrogenic diabetes insipidus is ________.
8. Urea is able to increase the osmotic pressure (__?___ osmolality) in _________.

132
 Na+ Reabsorption Thro’ Renin-Angiotensin-Aldosterone System (RAAS)
6 Renin Release

5
11
4
3
Glomerulus 3 2
Macula Densa 2
In Tubular Lumen

5
Juxta-glomerular Cells
Juxta = Near

1) Dehydration, Blood Loss à âECF Vol à âBP à âGFR (Glomerular Filtration Rate)
2) âFlow rate in LoH à áNa+ Reabsorption à â[Na+]o in Distal Tubule Lumen
3) MD (Macula Densa) Sense â[Na+]o à âNa+ Uptake into MD cells by Na+ K+ 2Cl− Co-transporter
4) â[Na+]i à Signal Transduction à ácAMP in JG (Juxta-Glomerular) Cells (5), JG are Smooth muscle located
in the capillaries of the kidney à Key Player in the RAAS à Release Renin (6) 133
 c t u r e [Dehydration, Blood Loss] à âBlood Vol, âBP, âBlood [Na+] à
ig P i
B Activate Renin-Angiotensin-Aldosterone System (RAAS) à Na+ Reabsorption
vs. (ADH à H2O Reabsorption)

Angiotensinogen (Produced by the Liver à Release to Blood, 452 aa, 1st 12 aa are useful)

Renin (Endopeptidase from Kidney)

Angiotensin I (10 aa): No Biological Activity

ACE-1 (Angiotensin Converting Enzyme-1; in Lung Endothelial Cells)

Angiotensin II (1-8 aa)

Fast Action: AT1R (Angiotensin II Type 1 R) in Adrenal Cortex

Blood Vessels: AT1R Binding (AT2R: Involved in development, cell differentiation, repair & apoptosis)
à áCa2+ à Smooth Muscle Slow Action:
Contraction à áBP
Aldosterone (Steroid Hormone from Adrenal Glands (Cortex))

Renal Tubule: Na+-Reabsorption, K+-Secretion, n R ule

Golde
followed by H2O Reabsorption in Kidney CDs
134
 Aldosterone: Na+-Reabsorption - Principal Regulator Site for Regulation
1) The Principal Epithelial Cell (transport Na+,K+,H2O) is Aldo-sensitive at DCT (5 mm in length) & CD.
2) Aldosterone (Steroid Hormone) produced in the Adrenal Cortex. vs. ADH (Pituitary Gland)
3) Aldosterone + Cytoplasmic Receptor à Transcription Factor à Gene expression (Classical, Hrs)
4) áNa+/K+-ATPase & Na+-, K+-channel Proteins Expression on different sides
5) Na+-Reabsorption & K+ Secretion, Followed by H2O Reabsorption: ~5% of Total Na+ Reabsorption
6) Aldosterone à Metabolites (Aldosterone 21-oleate) in Liver & Excreted by Kidneys, 1/2 life: 10-20 min.
1 Renal ISF
Basolateral
Side ~95% Na+ Intake
2
Non-polar
Apical Surface

3
5
K+ secretion
linked to Na+ 4c
reabsorption

4b 4a
Na+ Channel Transcellular P ≠
blocked by Amiloride Paracellular Pathway
http://cwx.prenhall.com/bookbind/pubbooks/silverthorn2/medialib/Image_Bank/CH19/FG19_12.jpg 135
 High K+ Diet à Induce Hypertension??

Apical
Surface

• Aldosterone Action: Na+-Reabsorption, K+-Secretion, followed by H2O Reabsorption in Kidney CDs

• High K+ Diet à áNa+-Reabsorption, áH2O Reabsorption? à áBP à Hypertension Induction??
• Contradictory to our Experience/Observations??

136
 The Potassium Switch
• Ancient Diet: Vegetables/Fruits (áK+ âNa+ âCl-) à Human kidneys adapted for Na+ reabsorption & K+ excretion.
• Modern Diet: âK+ à Kidneys à Turn on K+ Retention Mechanism à Hypertension

In DCT (distal convoluted tubule) Cells (1):

1
Plasma K+â (2) à K+ Switch in On Mode (3)
à K+ efflux to the blood thro’ K+ Channels (4) Kinase 7 Kinase No
Activation Activation
(on the Basolateral side, more sensitive to change in MP)
8 Cl- Channel 5
à Cl- efflux thro’ Cl- Channels by membrane âCl- áCl-
Cl- Channel

voltage (5) à âCl- in ICF (6) à Kinase-p (7) 6 K+ Channel

4 K+ Channel

à NCC-p (NaCl Co-transporter) à áNa+ & Cl- 2 Plasma

Reabsorption from Lumen (8) à Lumen with 9 K+á
âNa+

• Next in Principal Cells (9) : âNa+ in Lumen

à âNa+ Reabsorption & âK+ Secretion à
Limited K+ Secretion in the CD (Keep áK+ in
3 K+ Switch On K+ Switch Off
plasma !) Natriuresis (áNa+ Excretion in the Urine)

• DCT is a K+ Sensor à Low K+ diet turns on ENaC: Epithelial Na+ Channel

ROMK: Renal Outer Medullary K+ Channel
the K+ Switch Pathway to Conserve K+ at the
Expense of Increasing Na+ Retention & this
Increases BP. Q&A: What are the mechanisms to reduce BP
Adv Kidney Dis Health, 2023, 30:137-147. by taking high K+ diets (More Bananas)? 137
Renin–Angiotensin–Aldosterone System (RAAS)
Bodily Fluid & Electrolyte Balance + BP Regulation
à Maintain BP & Blood Volume

ACEIs (Angiotensin Converting Enzyme

Inhibitors) à âBP (Hypertension)

ARBs

ARBs (Angiotensin receptor blockers) âBP

by Blocking Angiotensin II à
(1) Relax Blood Vessels (Blood Flow Easier);
(2) âSalt & Water in our body.
138
 Q&A: RAAS, ACEI & ARBs
ACE is expressed abundantly in lung
capillaries, why? â 2a
1a
Dry cough is the side effect of ACEI, how? Angiotensinogen (by liver, 452 aa) ACE Inhibitor (ACEI)
• âAngiotensin II Release
Renin (Endopeptidase Kidney) â 2b • ACEI à âBradykinin Degradation

3
Angiotensin I (10 aa) - à áBradykinin à âBP
ACE-2 (Discovered in 2000): • ACEIs are Potent Diuretics
Angiotensin1-7 ACE-1 (Lung) â
• ACEI’s names ended with ….pril
â

Potent Vasodilator R for SARS-1/-2 Virus Entry

Angiotensin II (1st 1-8aa) (e.g. Lisinopril)

â
ACE2 Not inhibited by ACEI 2c
â
â â
Mas Receptor 4 2e
(Mito Assembly Receptor) Fast Action: Slow Action: Adrenal Cortex à Bradykinin
â VasoConstrictor àáBP Aldosterone (Steroid Hormone) • 9 aa peptide hormone,
Pain Relief, Anti-fibrosis, â 10X potent > Histamine,
Anti-Inflammation, 1b áCapillary Permeability
Na+-Reabsorption & K+-Secretion, Powerful Vasodilator.
Anti-oxidant,Vasodilation followed by H2O Reabsorption e n R ule
G old • Breakdown by ACE-1.
5 Kidney Epithelial Cell à áB Vol
Ex à áACE2 à 2f
âMenstruation ACEI Side Effect: à Inhibit ACE-1 à
Pain & Cramp áBradykinin à áH2O, Proteins & Eosinophils
2d âAldosterone à Polyuria à âBP à Lungs à Dry Cough.
139

6
ARBs (Angiotensin receptor blockers) (e.g. Losartan): âBP by Blocking Ang II à
(1) Relax Blood Vessels (Blood Flow Easier); (2) âSalt & Water in our body.
[Losartan (Cozaar) Side effects: Dizziness, Tiredness. 139
 Key Concepts
1. In what part of the nephron does regulated Na+-reabsorption occur?
2. Two sensing receptors (Blood Vol R in the Heart, Osmoreceptors in the Hypothalamus)
are used for the Na+ and water balance in our body. Which one has a higher sensitivity?
3. Angiotensin II stimulates the secretion of this hormone. This hormone is known as?
4. What structure detects changes in the delivery of Na+ to the distal tubule?
5. This factor is the rate-limiting step in the production of angiotensin I.
6. The hormone secreted by the Juxta-glomerular cells.
7. What hormone binds to cytoplasmic receptors for the expression
of more channels & pumps to kick off Na+ reabsorption and K+ secretion?
8. What is the difference between ADH & Aldosterone in terms of H2O reabsorption?

140
 Key Concepts

https://www.dovepress.com/cr_data/article_fulltext/s79000/79302/img/fig1.jpg 141
Hyperkalemia & Hypokalemia Hyper: >Normal; Hypo: <Normal; Kal: K+; Mia: Blood

Hyperkalemia (mM) Hypokalemia (mM)

Serum [K+] > 6.0, Treatment: Diuretics Water Pills 3.5 - 5.0, Treatment: Diet, Oral Supplement
Mechanism • Normal Function of K+ à Memb Potential à Electrical Signal in the Muscle & Nervous System
• Mess up à Problems in the Heart, GI, Renal, & Breathing muscles.

Cause • Burns, Tissue damages: K+ loss from ICF à ECF • Over-production of Aldosterone*
• Adrenal Insufficiency à âAldosterone* • Fluid Loss from Wounds, Sweating
• Drugs: ACE Inhibitors, NSAIDsàâAldosterone
• Renal Failure

*Aldosterone: Na+-Reabsorption & K+-Secretion, followed by H2O Reabsorption

Symptoms Muscle Weakness à Respiratory Failure / Cardiac Problems à âBP

29/1/2019

142
 Experience in Our Daily Life – Slow K

A drug company terminated its supply of potassium pills (鉀丸) known as ‘Slow-K’ possibly due to lead
contamination. Slow-K is a tablet containing 8 mmole of KCl in a wax matrix for oral administration.

Two pills are given to patients with hypertension daily to prevent hypokalemia (low blood K+ level) who
receive diuretic therapy.

A medical officer suggested giving the patients a KCl Solution of the same dose by oral administration.
What are your comments?

19/3/2018

143
Hypernatremia & Hyponatremia NatreMia: Na+ level in the Blood

Hypernatremia (mM) Hyponatremia (mM)

Serum [Na+] >145, Treatment: H2O Drinking, IV Fluid Therapy <135, Treatment: Diet, IV Fluid &
Electrolyte replacement
Mechanism Where Na+ goes, water goes. They love each other. But they are regulated independently.
Hypernatremia (H2O Retention) à A H2O problem rather than a Na+ Problem
e.g. confusion, coma, due to the osmotic shift of water out of brain cells
Hyponatremia: Problems for Na+ to regulate water inside and outside of the cell
Cause • áNa+ intake • Increases ADH Production
• Aldosterone Overproduction • Drinking too much Water
• Loss of Fluids: sweating, Diabetes Insipidus (ADH) • ACE Inhibitors
• Thirst Impairment

Symptoms Increased Fluid Retention, Edema, âUrine Output, Headache, Confusion, Muscle Cramps

144