Making sense of the sensor: Mysteries of the macula densa

Increases in luminal NaCl concentration at the macula densa (MD), the sensing element, activate tubuloglomerular feedback (TGF). MD cell volume increases when increments are isosmotic and shrinks if osmolality increases. This interesting finding introduces additional complexity to the role of the MD in TGF

Physiologic adaptations of the tubuloglomerular feedback system

The maintenance of volume homeostasis is sufficiently important to mammalian terrestrial life that a large amount of evolutionary energy has been expended in the development of multiple control systems, each involved in regulating the volume and composition of internal body fluids. The kidney, which participates in most of these systems, has evolved physiologic attributes which enhance the efficiency of volume regulation. Perhaps the most fundamental of these attributes is a close coordination between the processes of glomerular filtration and tubular reabsorption. Such coordination is required to prevent the amplification of small fluctuations in glomerular filtration rate into large fluctuations in total body salt and water content.It was first suggested by Homer Smith that reabsorption of fluid from the nephron should increase as the delivery of tubular fluid into that segment increases [1]. When applied to the proximal tubule, this principle of flow-dependent transport has come to be referred to as “glomerulotubular balance” [2, 3]. Glomerulotubular balance depends upon intrinsic properties of the proximal nephron including the affinities and densities of various solute transporters and the differential permeabilities of the nephron to various solutes and water, and upon the trans-epithelial concentration gradients of these solutes [4–6]. By definition, glomerulotubular balance describes the functional dependence of tubular reabsorption on glomerular filtration rate independently of other neuro-humoral effectors of tubular transport. However, since glomerulotubular balance is a substrate-driven process, it cannot accomplish an increment in proximal tubular reabsorption which exceeds an increment in delivered load. Therefore, in the absence of effectors other than glomerulotubular balance the volume of fluid entering the distal nephron must be a monotonically increasing function of GFR [7].How then, may the kidney avert an unintentional diuresis should the hemodynamic forces favoring glomerular filtration combine to overwhelm the reabsorptive capacity of the nephron? In 1937 Goormaghtigh suggested that the juxtaglomerular apparatus might participate in the maintenance of volume homeostasis by generating some sort of signal in response to changes in the composition of distal tubular fluid [8]. The peculiar anatomic arrangement of the nephron would facilitate transmission of this signal to the upstream glomerulus and lead to alterations in the physiologic determinants of glomerular filtration. This hypothesis has been refined over the past three decades as substantial experimental data have accrued to support the existence of an operational system of tubuloglomerular feedback (TGF) [9]. Contemporary models of the TGF system, by analogy to negative feedback-driven control systems in engineering control theory, divide the system into three component processes [10]. The first of these components is a parameter which the system is designed to regulate, in this case, the rate at which tubular fluid transits the late proximal nephron or VLP. The second component includes the macula densa and surrounding interstitium which serve to detect differences between the current value of VLP and some internal set-point, and translate this information into an output command. The third component, or effector limb, of the TGF system is constituted by the contractile glomerular mesangium and glomerular arterioles which respond to the aforementioned output command by altering nephron filtration rate (SNGFR) to keep VLP in line with the system's internal set-point. When TGF is allowed to function as a closed-loop system [7], as is the case in vivo, its presence is, by nature, undetectable. However, when late proximal flow is uncoupled from nephron filtration by artificial microperfusion of the late proximal tubule, a dependence of SNGFR on VLP can be defined [11]. This relationship is referred to as the “TGF function”, or “gain” of the TGF system [7, 10]. This TGF function specifies a continuum of points in the VLP-SNGFR plane at which the nephron may operate. The actual operating point of the system exists at the point in this plane where the TGF and glomerulotubular balance functions intersect (Fig. 1).The TGF function may vary in response to the changing needs of the organism, both with regard to volume homeostasis and renal function. The altering of TGF under conditions of pregnancy, loss of renal mass, and a variety of other pathophysiologic conditions suggests that the juxtaglomerular apparatus is involved in events pertinent not merely to volume regulation but to overall renal growth and function

Disassociation between glomerular hyperfiltration and extracellular volume in diabetic rats

Disassociation between glomerular hyperfiltration and extracellular volume in diabetic rats. The relationship of the development of glomerular hyperfiltration in diabetes to changes in extracellular fluid volume has not been previously examined. To accomplish this task, male Wistar rats were chronically cannulated in the bladder, femoral artery and vein. Control measurements of glomerular filtration rate (GFR), renal plasma flow (RPF), extracellular fluid volume (ECF), and urinary sodium excretion were performed on two separate days prior to infusion of streptozotocin (65 mg/kg body wt i.v.). After infusion of streptozotocin, the IDDM rats were separated into two groups: untreated IDDM group of rats and IDDM rats treated with insulin at doses sufficient to normalize blood glucose (Ultralente, 2 to 8 IU/day). A third group of normal non-diabetic rats served as time controls. Measurements of renal function occurred at 1, 4, 7, 11, and 15 days after infusion of streptozotocin. Blood glucose in the non-diabetic measurement period averaged 137 ± 30 mg/dl and increased from 412 ± 55 after 24 hours in the untreated diabetic rats to 533 ± 33 mg/dl after 15 days of IDDM. The time controls and the insulin-treated diabetic rats did not differ in blood glucose values at the time measurements were performed. Glomerular filtration rate increased from 1.0 ± 0.1 to 1.7 ± 0.1 ml/min/100g body wt by day 15 in the untreated diabetic rats with significant increases in GFR within 24 hours. GFR of both time controls and the insulin-treated IDDM rats did not significantly vary during the time of the study. The increase in GFR in the untreated IDDM group was associated with a concomitant increase in RPF. However, ECF decreased in both the insulin treated and untreated groups by one day after streptozotocin infusion and was less than control throughout the 15 day IDDM measurement period. Therefore, the data indicate that the development of hyperfiltration in IDDM is not caused by ECF expansion and cannot be temporally linked to changes in ECF

Tubuloglomerular feedback responses of the downstream efferent resistance: Unmasking a role for adenosine?

This Commentary aims to integrate or interrelate the available in vivo data with the in vitro study by Ren and co-workers, which comes to the somewhat surprising conclusion that tubuloglomerular feedback activation vasodilates the efferent arteriole by an adenosine-dependent mechanism

A single nephron model of acute tubular injury: Role of tubuloglomerular feedback

A single nephron model of acute tubular injury: Role of tubuloglomerular feedback. A single nephron model of nephrotoxic tubular injury was established to examine the mechanism whereby acute tubular damage contributes to reductions in nephron filtration rate (SNGFR). Acute microperfusion of 0.5ng of uranyl nitrate (UN) into the early proximal tubule produced a significant reduction (16 to 30%) in SNGFR measured in both distal and proximal tubules of the same nephron and a decrease in absolute proximal reabsorption. Microperfused inulin was retained in the tubule suggesting this finding reflected a true reduction in SNGFR. Concurrent infusion of high dose furosemide (2 × 10-4M) and bumetanide (2 × 10-5M), but not low dose furosemide (2 × 10-5M), prevented the UN induced reduction in SNGFR. High dose furosemide begun after UN perfusion also prevented reduction in SNGFR. Continuous direct measurement of glomerular capillary hydrostatic pressure revealed no change. Distal intratubular Na+ and CI- concentration increased significantly after UN perfusion. Activation of tubuloglomerular feedback mechanisms best explains the reduction in glomerular ultrafiltration that is characteristic of nephrotoxic forms of tubular injury

Development of an invasively monitored porcine model of acetaminophen-induced acute liver failure

Background: The development of effective therapies for acute liver failure (ALF) is limited by our knowledge of the pathophysiology of this condition, and the lack of suitable large animal models of acetaminophen toxicity. Our aim was to develop a reproducible invasively-monitored porcine model of acetaminophen-induced ALF. Method: 35kg pigs were maintained under general anaesthesia and invasively monitored. Control pigs received a saline infusion, whereas ALF pigs received acetaminophen intravenously for 12 hours to maintain blood concentrations between 200-300 mg/l. Animals surviving 28 hours were euthanased. Results: Cytochrome p450 levels in phenobarbital pre-treated animals were significantly higher than non pre-treated animals (300 vs 100 pmol/mg protein). Control pigs (n=4) survived 28-hour anaesthesia without incident. Of nine pigs that received acetaminophen, four survived 20 hours and two survived 28 hours. Injured animals developed hypotension (mean arterial pressure; 40.8+/-5.9 vs 59+/-2.0 mmHg), increased cardiac output (7.26+/-1.86 vs 3.30+/-0.40 l/min) and decreased systemic vascular resistance (8.48+/-2.75 vs 16.2+/-1.76 mPa/s/m3). Dyspnoea developed as liver injury progressed and the increased pulmonary vascular resistance (636+/-95 vs 301+/-26.9 mPa/s/m3) observed may reflect the development of respiratory distress syndrome. Liver damage was confirmed by deterioration in pH (7.23+/-0.05 vs 7.45+/-0.02) and prothrombin time (36+/-2 vs 8.9+/-0.3 seconds) compared with controls. Factor V and VII levels were reduced to 9.3 and 15.5% of starting values in injured animals. A marked increase in serum AST (471.5+/-210 vs 42+/-8.14) coincided with a marked reduction in serum albumin (11.5+/-1.71 vs 25+/-1 g/dL) in injured animals. Animals displayed evidence of renal impairment; mean creatinine levels 280.2+/-36.5 vs 131.6+/-9.33 mumol/l. Liver histology revealed evidence of severe centrilobular necrosis with coagulative necrosis. Marked renal tubular necrosis was also seen. Methaemoglobin levels did not rise >5%. Intracranial hypertension was not seen (ICP monitoring), but there was biochemical evidence of encephalopathy by the reduction of Fischer's ratio from 5.6 +/- 1.1 to 0.45 +/- 0.06. Conclusion: We have developed a reproducible large animal model of acetaminophen-induced liver failure, which allows in-depth investigation of the pathophysiological basis of this condition. Furthermore, this represents an important large animal model for testing artificial liver support systems

Some biomarkers of acute kidney injury are increased in pre-renal acute injury

Pre-renal acute kidney injury (AKI) is assumed to represent a physiological response to underperfusion. Its diagnosis is retrospective after a transient rise in plasma creatinine, usually associated with evidence of altered tubular transport, particularly that of sodium. In order to test whether pre-renal AKI is reversible because injury is less severe than that of sustained AKI, we measured urinary biomarkers of injury (cystatin C, neutrophil gelatinase-associated lipocalin (NGAL), γ-glutamyl transpeptidase, IL-18, and kidney injury molecule-1 (KIM-1)) at 0, 12, and 24 h following ICU admission. A total of 529 patients were stratified into groups having no AKI, AKI with recovery by 24 h, recovery by 48 h, or the composite of AKI greater than 48 h or dialysis. Pre-renal AKI was identified in 61 patients as acute injury with recovery within 48 h and a fractional sodium excretion <1%. Biomarker concentrations significantly and progressively increased with the duration of AKI. After restricting the AKI recovery within the 48 h cohort to pre-renal AKI, this increase remained significant. The median concentration of KIM-1, cystatin C, and IL-18 were significantly greater in pre-renal AKI compared with no-AKI, while NGAL and γ-glutamyl transpeptidase concentrations were not significant. The median concentration of at least one biomarker was increased in all but three patients with pre-renal AKI. Thus, the reason why some but not all biomarkers were increased requires further study. The results suggest that pre-renal AKI represents a milder form of injury

How bold is blood oxygenation level dependent (BOLD) magnetic resonance imaging of the kidney? Opportunities, challenges and future directions

Renal tissue hypoperfusion and hypoxia are key elements in the pathophysiology of acute kidney injury and its progression to chronic kidney disease. Yet, in vivo assessment of renal haemodynamics and tissue oxygenation remains a challenge. Many of the established approaches are invasive, hence not applicable in humans. Blood oxygenation level dependent (BOLD) magnetic resonance imaging (MRI) offers an alternative. BOLD-MRI is non-invasive and indicative of renal tissue oxygenation. Nonetheless recent (pre-)clinical studies revived the question as to how bold renal BOLD-MRI really is. This review aims to deliver some answers. It is designed to inspire the renal physiology, nephrology, and imaging communities to foster explorations into the assessment of renal oxygenation and haemodynamics by exploiting the powers of MRI. For this purpose the specifics of renal oxygenation and perfusion are outlined. The fundamentals of BOLD-MRI are summarized. The link between tissue oxygenation and the oxygenation sensitive MR biomarker T2 * is outlined. The merits and limitations of renal BOLD-MRI in animal and human studies are surveyed together with their clinical implications. Explorations into detailing the relation between renal T2 * and renal tissue partial pressure of oxygen (pO2 ) are discussed with a focus on factors confounding the T2 * versus tissue pO2 relation. Multi-modality in vivo approaches suitable for detailing the role of the confounding factors that govern T2 * are considered. A schematic approach describing the link between renal perfusion, oxygenation, tissue compartments and renal T2 * is proposed. Future directions of MRI assessment of renal oxygenation and perfusion are explored

Multiparametric renal magnetic resonance imaging: validation, interventions, and alterations in chronic kidney disease

Background: This paper outlines a multiparametric renal MRI acquisition and analysis protocol to allow non-invasive assessment of hemodynamics (renal artery blood flow and perfusion), oxygenation (BOLD T2*), and microstructure (diffusion, T1 mapping). Methods: We use our multiparametric renal MRI protocol to provide (1) a comprehensive set of MRI parameters [renal artery and vein blood flow, perfusion, T1, T2*, diffusion (ADC, D, D*, fp), and total kidney volume] in a large cohort of healthy participants (127 participants with mean age of 41 ± 19 years) and show the MR field strength (1.5 T vs. 3 T) dependence of T1 and T2* relaxation times; (2) the repeatability of multiparametric MRI measures in 11 healthy participants; (3) changes in MRI measures in response to hypercapnic and hyperoxic modulations in six healthy participants; and (4) pilot data showing the application of the multiparametric protocol in 11 patients with Chronic Kidney Disease (CKD). Results: Baseline measures were in-line with literature values, and as expected, T1-values were longer at 3 T compared with 1.5 T, with increased T1 corticomedullary differentiation at 3 T. Conversely, T2* was longer at 1.5 T. Inter-scan coefficients of variation (CoVs) of T1 mapping and ADC were very good at <2.9%. Intra class correlations (ICCs) were high for cortex perfusion (0.801), cortex and medulla T1 (0.848 and 0.997 using SE-EPI), and renal artery flow (0.844). In response to hypercapnia, a decrease in cortex T2* was observed, whilst no significant effect of hyperoxia on T2* was found. In CKD patients, renal artery and vein blood flow, and renal perfusion was lower than for healthy participants. Renal cortex and medulla T1 was significantly higher in CKD patients compared to healthy participants, with corticomedullary T1 differentiation reduced in CKD patients compared to healthy participants. No significant difference was found in renal T2*. Conclusions: Multiparametric MRI is a powerful technique for the assessment of changes in structure, hemodynamics, and oxygenation in a single scan session. This protocol provides the potential to assess the pathophysiological mechanisms in various etiologies of renal disease, and to assess the efficacy of drug treatments