5.

8 Osmolality

1. Define osmolality and explain the importance of maintaining plasma osmolality within a given range.

- Osmolality is the concentration of body fluids measured in terms of the amount of osmolatically active solutes per unit mass of water in
mmol/kg

- A major determinant of total body water homeostasis → importance of maintaining plasma osmolality to prevent cell shrinking and lysis,
maintain concentration gradient, mediate membrane depolarization (nerve impulse and muscle contraction) and create optimum environment
for enzymes

- Normal Plasma Osmolality Level = 280 to 300 mmol/kg

- Measured by the concentrations of Sodium, Urea and Glucose → 2x [Na] + [Urea] + [Glucose]

- Any increase in plasma osmolality will increase the tonicity and stimulates:

a. Thirst center
b. Vasopressin secretion → vasopressin stimulates V2 receptors in the renal tubules causing increased water reabsorption

- Decreased plasma osmolality inhibits thirst centre and decreases vasopressin secretion, leading to diuresis (increased urine secretion)

- Plasma osmolality also governs the movement of water moving into and out of interstial fluids

- If osmolality is outwith the normal range, cells may either shrink or swell and thus become structurally fragile and functions will be impaired

2. Describe the processes within the kidney that determine the volume of urine produced in a healthy individual.

STRUCTURE OF KIDNEY

- Kidney consists of 3 parts → renal cortex, renal pelvis, renal medulla

- Renal Cortex contains the nephron → basic functional unit of the kidney

Cortical Nephrons (85%) Juxtamedullary Nephrons (15%)

Renal corpuscles lie in outer portion of renal cortex Renal corpuscles lie in deep region of cortex
Short loops of Henle that lie in cortex and penetrate superficial part of Long loops of Henle that extend into the deepest region of medulla
medulla
Loops of Henle receive blood supply from peritubular capillaries that Loops of Henle receive blood supply from the vasa recta that arises
arise from efferent arterioles from the peritubular capillaries
- Contains the juxtaglomerular apparatus that detects blood flow and
release renin
Perform excretory and regulatory functions Concentrate and dilute urine

PRODUCTION OF URINE
- Involves 2 parts

a. Countercurrent Multiplier mechanism that takes place in the loop of Henle

b. Reabsorption of Water in the collecting duct

1. Countercurrent Multiplier

- Renal mechanism by which urine is concentrated and whereby the unique solute transport process within the loop of Henle and generates
an increasing longitudinal gradient of salt concentration in the medulla → enables excess water to be withdrawn by osmosis from the urine
in the collecting duct

- Principles

- Fluid flows downward in the descending loop and upwards in the ascending loop
- Thin walls of the descending limb are permeable to water, while thick walls of the ascending limb are impermeable to water
- Ion pumps are present in the walls of the ascending limb that remove Na+ and Cl- into the medullary interstitial fluid

- Mechanism

- Fluid with an osmolality of 300 mmol/kg (isotonic) flows through the descending limb of the loop of Henle
- Activation of ion pumps in the ascending limb causes Na+ and Cl- to flow out of the fluid into the medullary interstitial fluid
- Osmolality of fluid in the ascending limb decreases and osmolality of medullary interstitial fluid increases
- Water starts to flow out of the descending limb via osmosis because of the osmolality gradient
- Sequential effect of losing more fluid in the descending limb and the activation of the ion pump in the thick ascending limb multiplies
the effectiveness of the countercurrent and creates an area of high osmolality around the turn of the loop

Simple Cuboidal Cells

(containing numerous
mitochondria)

Simple Squamous
Cells 3 Factors affecting the concentrative function

Increased length of loop

Increased capacity of the ion pump in the thick

ascending limb

Reduced flow rate through the loop

2. Collecting Duct

- Involves the action of vasopressin (ADH)

- ADH is released by the posterior pituitary gland during conditions of water deprivation and acts to increase the water permeability of all
segments of the collecting duct
- Water reabsorption occurs by osmosis from the hypotonic fluid in the collecting duct to the medullary interstitial fluid due to the presence
of the osmolality gradient
- Reabsorbed water is carried away immediately by the vasa recta → medullary interstitial osmolality gradient intact
- Only involved in concentrating or diluting urine → most water reabsorption occurs in PCT and LH (obligatory water reabsorption with
Na+)

- Conditions

Concentration of Urine Dilution of Urine

Adequate solute delivery to the loop of Henle Adequate solute delivery into the loop of Henle and early distal
tubule
Normal function of the loop of Henle Normal function of the loop of Henle and early distal tubule
ADH release into the circulation No ADH circulation
 ADH action on the collecting ducts -

3. Describe the molecular and cellular components of the feedback loop that maintains water homeostasis and identify points where this
feedback could be disrupted.

- Water homeostasis is regulated by ADH (Vasopressin) → produced by cell bodies of 2 nuclei, supraoptic and paraventricular nuclei of the
hypothalamus and associated with a carrier protein (neurophysin II)

- With ADH, 1% of glomerular filtrate is secreted but without ADH, 8% is secreted

- The hormones are transferred to the posterior pituitary gland and stored in cytoplasmic granules in specialized nerve endings until it is
secreted into general circulation via the hypophyseal capillaries

- Mechanism of Vasopressin Action

- ADH works by binding to 2 important receptors located in different tissues and single cellular processes through different mechanisms

a. V1 Receptors

- Phospholipase C is activated by G-protein subunits and cause the hydrolysis of PIP2 (phosphatidylinositol) into IP3 (inositol
triphosphate) and DAG (diacylglycerol), both of which are secondary messengers
- DAG causes the activation of Protein Kinase C and IP3 opens calcium channels on the membrane → mobilisation of Ca2+ and
contraction
- Present on vascular smooth muscle → binding of ADH to V1 stimulates vasoconstriction
- Relatively high concentraitons of ADH is needed to elicit this vascular response

b. V2 Receptors

- Present in the renal tubles (last part of distal convoluted tubule and throughout the collecting duct)
- Act on principal cells (versus intercalated cells that is mainly invovled with acid-base balance)
- Binding of ADH to V2 activates G-proteins and subsuently adenylate cyclase (via GTP) which produces cAMP from ATP
- cAMP activates protein kinases and transcription factors (amplication cascade)
- Aquaporin molecules in the cell are phosphorylated and inserted into the plasma membrane at the luminar surface of epithelial cells via
exocytosis → forms water channels across membrane → water permeability increases
- Transcription factors bind to DNA and stimulate synthesis of more aquaporin molecules forming more water channels in the membrane

- Control of Vasopressin Secretion

a. Osmotic Stimuli (osmolality)

- Detection of plasma osmolality by osmoreceptors present in the anterior hypothalamus

- Increased stimulation results in vasopressin secretion and increased thirst
- Maintained at 285 mmol/kg

b. Cardiovascular Reflex (stretch)

- Present in both atrial and pulmonary arteries

- Stretching of the receptors sends signals to the hypothalamus to decrease secretion of ADH

c. Arterial Baroreceptor Reflex (BP)

- Pressure receptors
- Present in wall of large arteries in thoracic and neck region (carotid sinus and wall of aortic arch)
- Decrease in blood volume → BP falls → less discharge by carotid and aortic baroreceptors → increased secretion of ADH

d. Angiotensin → released in response to hypovolemia and hypotension and acts on cirumventricular organs to increase vasopressin secretion

- Possible Disruption to Feedback Loop

- Failure of osmoreceptors to detect changes in osmolality

- Failure of baroreceptors to detect changes in pressure
- Failure of hypothalamus to recognise input stimuli
- Failure of posterior pituitary gland to secrete ADH
- Failure of binding of ADH on V1 and V2 receptors
- Failure of insertion of aquaporins into luminal membrane
- ADH secretion is also inhibited by alcohol intake and its effects are countered by the action of Atrial Natriuretic Peptide

4. Describe and explain the signs and symptoms of excessive water loss or retention.

- Dehydration is the excessive loss of water from the body → result from inadequate water intake and/or from excessive removal of water

Signs and Symptoms Causes

Mild (1 to 2L) Thirst Stimulation of thirst centre in hypothalamus
Concentrated urine Increased reabsorption of water → influenced by ADH and RAA system
Moderate (2 to 4L) Marked thirst, difficulty in Stimulation of thirst centre in hypothalamus
swallowing
Dizziness Decreased blood flow to brain
Oliguria (decreased urine Increased reabsorption of water → influenced by ADH and RAA system
production)
Inability to sweat Parasympathetic stimulation and sympathetic inhibition to prevent water loss
Severe (4 to 10L) Severe thirst Stimulation of thirst centre in hypothalamus
Confusion, coma Decreased blood flow to brain
Dry skin, poor turgor Decreased peripheral perfusion → vasoconstriction of blood vessels
Tachycardia Decrease in blood volume results in compensatory increase in HR
Low BP Decrease in blood volume

- Water retention is the inability to get rid of excess water resulting in water being retained in the body (caused by heart and renal failure)

- Signs and Symptoms

a. Feelings of tightness in the arm or leg → skin that feels stiff or taut
b. Decreased flexibility in a hand, elbow, wrist, fingers or leg
c. Difficulty fitting into clothing
d. Pain, aching, heaviness, or weakness in the arm or leg
e. Redness, swelling or signs of infection
f. Pitting (small indentations left on the skin after pressing on the swollen area)

5. Discuss the role of desmopressin in the treatment of diabetes insipidus, and explain why this compound is used rather than the
physiological hormone.

- Desmopressin is the synthetic version of vasopressin and comes in a liquid form that is administered through a tube or through a nasal spray

- Works by increasing urine concentration and decreasing urine production

- Helps to:

a. Prevent and control excessive thirst, urination and dehydration caused by physical injury, surgery and medical conditions
b. Reduces frequent trips to the toilet in the night,
c. Chronic autonomic failure (unable to control urine production)

- Advantages of Desmopressin

- Degraded much slower than recombinant vasopressin → requires less frequent administration
- Site-selective (V2 receptors) → little influence on BP while vasopressin may cause hypertension
- Used in clotting diseases as well → mediate release of CF VIII (anti-haemophilic factor) and von Willebrand’s factor

- Diabetes Insipidus

- A disorder in which the patient produces large amount of dilute urine and is constantly thirsty
- Due to deficiency of pituitary hormone vasopressin (ADH) which regulates reabsorption of water in the kidneys
- Also due to failure of ADH action at the renal tubular level

- Types and Causes

a. Neurogenic DI

- Due to damage to the hypothalamus or pituitary due to a tumor, stroke or infection

 - If the hypothalamus is damaged, the feeling of thirst may be completely absent

b. Nephrogenic DI

- Due to kidney damage (rarer)

- Occurs as a side-effect to some medication (lithium citrate → for schizophrenia), in polycystic kidney disease (PKD) and sickle-cell
anemia, defect of vasopressin receptor gene and hypercalcaemia

c. Dipsogenic DI

- Due to a defect or damage to the thirst mechanism (located in the hypothalamus)

- Results in an abnormal increase in thirst and fluid intake that suppresses ADH secretion and increases urine output
- Desmopressin is ineffective and can lead to fluid overload as the thirst remains

d. Gestational DI

- Only occurs during pregnancy

- Extreme forms of vasopressinase (breaks down ADH) in the placenta can be assumed
- Most cases can be treated with desmopressin
- In rare cases, an abnormality in the thirst mechanism causes gestational DI, and desmopressin should not be used

- Symptoms

- Polyuria → excessive urine production up to 10 to 15 L

- Nocturia → excessive urine production in the night
- Polydipsia → chornic excessive thirst
- Dehydration
- Fatigue
- Dryness of Lips

6. Explain the general principles underlying homeostasis, and the differences between positive and negative feedback.

- Homeostasis is the restoration and maintenance of the normal parameters of a biological system in response to small external changes

- Stimulus includes Temperature, Blood Glucose Level, Tissue Damage, Exercise, Stress and Infections

- Stimulus triggers signaling mechanisms that work via hormones and nerve impulses that serve to alter:

a. Rate of formation of enzymes

b. Expression of genes through transcription factors
c. Opening and closing of ion channels
d. Cell replication

- Regulation works in the form of a feedback system which is a cycle of events that is continually monitored, evaluated and changed

- Components of a Homeostatic system

a. Controlled Condition → the monitored variable

b. Stimulus → a disruption that can cause a change to the controlled condition beyond the normal range
c. Receptor → a structure that monitors changes in a controlled condition and sends inputs (chemical or nervous) to the control centre
d. Control Centre → sets the range of values in which the controlled condition should be maintained and evaluates inputs and generates
outputs in the form of nerve impulses, hormones or chemical signals
e. Effector → receives output from the control centre and produces responses that restores the controlled condition within normal range
 Receptor
Stimulus
Baroreceptors detect fall in
Haemorrhage
BP and sends nervous input
BP ↓
to brain

Controlled Condition Control Centre

Blood Pressure altered Cardiovascular Centre

by stimulus and restored processes input and
eventually by sends nervous output to
homeostasis effectors
Effecter

Sympathetic stimulation and

parasympathetic inhibition of
BP ↑ Myocardium → Increased CO

Sympathetic vasoconstriction of
Blood Vessels → Increased TPR

- Homeostasis mechanisms depend on feedback response

a. Positive Feedback

- A change which strengthens or reinforces the change in the controlled condition

- Action continues until it is interrupted by some mechanism outside the system
- Blood clotting and nervous transmission

b. Negative Feedback

- A change which aims to restore the original state of the controlled condition by opposing the change
- Action continues until the original state has been restored
- Blood glucose regulation and BP regulation

- Feed Forward → an anticipatory element in which effectors trigger response before a stimulus is received (anticipation of food on secretion of
gastric juice)

- Tissue-specific nature of signaling processes are the basis of homeostatic mechanism → depends upon the characteristics of cells