Ganong’s Review of Medical Physiology, 24th Edition
CHAPTER 38 Regulation of Extracellular Fluid Composition & Volume
After reading this chapter, you should be able to:
Describe how the tonicity (osmolality) of the extracellular fluid is maintained by alterations in water intake and vasopressin secretion.
Discuss the effects of vasopressin, the receptors on which it acts, and how its secretion is regulated.
Describe how the volume of the extracellular fluid is maintained by alterations in renin and aldosterone secretion.
Outline the cascade of reactions that lead to the formation of angiotensin II and its metabolites in the circulation.
List the functions of angiotensin II and the receptors on which it acts to carry out these functions.
Describe the structure and functions of ANP, BNP, and CNP and the receptors on which they act.
Describe the site and mechanism of action of erythropoietin, and the feedback regulation of its secretion.
This chapter is a review of the major homeostatic mechanisms that operate, primarily through the kidneys and the lungs, to maintain the tonicity, the volume, and the specific ionic composition of the extracellular fluid (ECF). The interstitial portion of this fluid is the fluid environment of the cells, and life depends upon the constancy of this “internal sea” (see Chapter 1).
DEFENSE OF TONICITY
The defense of the tonicity of the ECF is primarily the function of the vasopressin-secreting and thirst mechanisms. The total body osmolality is directly proportional to the total body sodium plus the total body potassium divided by the total body water, so that changes in the osmolality of the body fluids occur when a mismatch exists between the amount of these electrolytes and the amount of water ingested or lost from the body. When the effective osmotic pressure of the plasma rises, vasopressin secretion is increased and the thirst mechanism is stimulated; water is retained in the body, diluting the hypertonic plasma; and water intake is increased (Figure 38–1). Conversely, when the plasma becomes hypotonic, vasopressin secretion is decreased and “solute-free water” (water in excess of solute) is excreted. In this way, the tonicity of the body fluids is maintained within a narrow normal range. In health, plasma osmolality ranges from 280 to 295 mOsm/kg of H2O, with vasopressin secretion maximally inhibited at 285 mOsm/kg and stimulated at higher values (Figure 38–2).
FIGURE 38–1 Mechanisms for defending ECF tonicity. The dashed arrow indicates inhibition. (Courtesy of J Fitzsimmons.)
FIGURE 38–2 Relation between plasma osmolality and plasma vasopressin in healthy adult humans during infusion of hypertonic saline. LD, limit of detection. (Reproduced with permission from Thompson CJ, et al: The osmotic thresholds for thirst and vasopressin are similar in healthy humans. Clin Sci [Colch] 1986;71:651.)
There are at least three kinds of vasopressin receptors: V1A, V1B, and V2. All are G protein-coupled. The V1A and V1B receptors act through phosphatidylinositol hydrolysis to increase the intracellular Ca2+ concentration. The V2receptors act through Gs to increase cyclic adenosine 3’,5’-monophosphate (cAMP) levels.
EFFECTS OF VASOPRESSIN
Because one of its principal physiologic effects is the retention of water by the kidney, vasopressin is often called the antidiuretic hormone (ADH). It increases the permeability of the collecting ducts of the kidney, so that water enters the hypertonic interstitium of the renal pyramids. The urine becomes concentrated, and its volume decreases. The overall effect is therefore retention of water in excess of solute; consequently, the effective osmotic pressure of the body fluids is decreased. In the absence of vasopressin, the urine is hypotonic to plasma, urine volume is increased, and there is a net water loss. Consequently, the osmolality of the body fluid rises.
The mechanism by which vasopressin exerts its antidiuretic effect is activated by V2 receptors and involves the insertion of aquaporin 2 into the apical (luminal) membranes of the principal cells of the collecting ducts. Movement of water across membranes by simple diffusion is now known to be augmented by movement through these water channels. These channels are stored in endosomes inside the cells, and vasopressin causes their rapid translocation to the luminal membranes.
V1A receptors mediate the vasoconstrictor effect of vasopressin, and vasopressin is a potent stimulator of vascular smooth muscle in vitro. However, relatively large amounts of vasopressin are needed to raise blood pressure in vivo, because vasopressin also acts on the brain to decrease in cardiac output. The site of this action is the area postrema, one of the circumventricular organs (see Chapter 33). Hemorrhage is a potent stimulus for vasopressin secretion, and the blood pressure fall after hemorrhage is more marked in animals that have been treated with synthetic peptides that block the pressor action of vasopressin. Consequently, it appears that vasopressin does play a role in blood pressure homeostasis.
V1A receptors are also found in the liver and the brain. Vasopressin causes glycogenolysis in the liver, and, as noted above, it is a neurotransmitter in the brain and spinal cord.
The V1B receptors (also called V3 receptors) appear to be unique to the anterior pituitary, where they mediate increased secretion of adrenocorticotropic hormone (ACTH) from the corticotropes.
Circulating vasopressin is rapidly inactivated, principally in the liver and kidneys. It has a biologic half-life of approximately 18 min in humans.
CONTROL OF VASOPRESSIN SECRETION: OSMOTIC STIMULI
Vasopressin is stored in the posterior pituitary and released into the bloodstream in response to impulses in the nerve fibers that contain the hormone. The factors affecting its secretion are summarized in Table 38–1. When the effective osmotic pressure of the plasma is increased above 285 mOsm/kg, the rate of discharge of neurons containing vasopressin increases and vasopressin secretion occurs (Figure 38–2). At 285 mOsm/kg, plasma vasopressin is at or near the limits of detection by available assays, but its levels probably decrease when plasma osmolality is below this level. Vasopressin secretion is regulated by osmoreceptors located in the anterior hypothalamus. They are outside the blood–brain barrier and appear to be located in the circumventricular organs, primarily the organum vasculosum of the lamina terminalis (OVLT) (see Chapter 33). The osmotic threshold for thirst (Figure 38–1) is the same as or slightly greater than the threshold for increased vasopressin secretion (Figure 38–2), and it is still uncertain whether the same osmoreceptors mediate both effects.
TABLE 38–1 Summary of stimuli affecting vasopressin secretion.
Vasopressin secretion is thus controlled by a delicate feedback mechanism that operates continuously to defend the osmolality of the plasma. Significant changes in secretion occur when osmolality is changed as little as 1%. In this way, the osmolality of the plasma in normal individuals is maintained very close to 285 mOsm/L.
VOLUME EFFECTS ON VASOPRESSIN SECRETION
ECF volume also affects vasopressin secretion. Vasopressin secretion is increased when ECF volume is low and decreased when ECF volume is high (Table 38–1). There is an inverse relationship between the rate of vasopressin secretion and the rate of discharge in afferents from stretch receptors in the low- and high-pressure portions of the vascular system. The low-pressure receptors are those in the great veins, right and left atria, and pulmonary vessels; the high-pressure receptors are those in the carotid sinuses and aortic arch (see Chapter 32). The exponential increases in plasma vasopressin produced by decreases in blood pressure are documented in Figure 38–3. However, the low-pressure receptors monitor the fullness of the vascular system, and moderate decreases in blood volume that reduce central venous pressure without lowering arterial pressure can also increase plasma vasopressin.
FIGURE 38–3 Relation of mean arterial blood pressure to plasma vasopressin in healthy adult humans in whom a progressive decline in blood pressure was induced by infusion of graded doses of the ganglionic blocking drug trimethaphan. The relation is exponential rather than linear. (Drawn from data in Baylis PH: Osmoregulation and control of vasopressin secretion in healthy humans. Am J Physiol 1987;253:R671.)
Thus, the low-pressure receptors are the primary mediators of volume effects on vasopressin secretion. Impulses pass from them via the vagi to the nucleus of the tractus solitarius (NTS). An inhibitory pathway projects from the NTS to the caudal ventrolateral medulla (CVLM), and there is a direct excitatory pathway from the CVLM to the hypothalamus. Angiotensin II reinforces the response to hypovolemia and hypotension by acting on the circumventricular organs to increase vasopressin secretion (see Chapter 33).
Hypovolemia and hypotension produced by conditions such as hemorrhage release large amounts of vasopressin, and in the presence of hypovolemia, the osmotic response curve is shifted to the left (Figure 38–4). Its slope is also increased. The result is water retention and reduced plasma osmolality. This includes hyponatremia, since Na+ is the most abundant osmotically active component of the plasma.
FIGURE 38–4 Effect of hypovolemia and hypervolemia on the relation between plasma vasopressin (pAVP) and plasma osmolality (posm). Seven blood samples were drawn at various times from 10 normal men when hypovolemia was induced by water deprivation (green circles, dashed line) and again when hypervolemia was induced by infusion of hypertonic saline (red circles, solid line). Linear regression analysis defined the relationship pAVP = 0.52 (posm – 283.5) for water deprivation and pAVP = 0.38 (posm – 285.6) for hypertonic saline. LD, limit of detection. Note the steeper curve as well as the shift of the intercept to the left during hypovolemia. (Courtesy of CJ Thompson.)
OTHER STIMULI AFFECTING VASOPRESSIN SECRETION
A variety of stimuli in addition to osmotic pressure changes and ECF volume aberrations increase vasopressin secretion. These include pain, nausea, surgical stress, and some emotions (Table 38–1). Nausea is associated with particularly large increases in vasopressin secretion. Alcohol decreases vasopressin secretion.
In various clinical conditions, volume and other nonosmotic stimuli bias the osmotic control of vasopressin secretion. For example, patients who have had surgery may have elevated levels of plasma vasopressin because of pain and hypovolemia, and this may cause them to develop a low plasma osmolality and dilutional hyponatremia (see Clinical Box 38–1).
CLINICAL BOX 38–1
Syndrome of Inappropriate Antidiurectic Hormone
The syndrome of “inappropriate” hypersecretion of antidiuretic hormone (SIADH) occurs when vasopressin is inappropriately high relative to serum osmolality. Vasopressin is responsible not only for dilutional hyponatremia(serum sodium < 135 mmol/L) but also for loss of salt in the urine when water retention is sufficient to expand the ECF volume, reducing aldosterone secretion (see Chapter 20). This occurs in patients with cerebral disease (“cerebral salt wasting”) and pulmonary disease (“pulmonary salt wasting”). Hypersecretion of vasopressin in patients with pulmonary diseases such as lung cancer may be due in part to the interruption of inhibitory impulses in vagal afferents from the stretch receptors in the atria and great veins.
A significant number of lung tumors and some other cancers secrete vasopressin. There is a process called “vasopressin escape” that counteracts the water-retaining action of vasopressin to limit the degree of hyponatremia in SIADH. Studies in rats have demonstrated that prolonged exposure to elevated levels of vasopressin can lead eventually to down-regulation of the production of aquaporin-2. This permits urine flow suddenly to increase and plasma osmolality to fall despite exposure of the collecting ducts to elevated levels of the hormone; that is, the individual escapes from the renal effects of vasopressin.
Patients with inappropriate hypersecretion of vasopressin have been successfully treated with demeclocycline, an antibiotic that reduces the renal response to vasopressin.
Diabetes insipidus is the syndrome that results when there is a vasopressin deficiency (central diabetes insipidus) or when the kidneys fail to respond to the hormone (nephrogenic diabetes insipidus).
Causes of vasopressin deficiency include disease processes in the supraoptic and paraventricular nuclei, the hypothalamohypophysial tract, or the posterior pituitary gland. It has been estimated that 30% of clinical cases are due to neoplastic lesions of the hypothalamus, either primary or metastatic; 30% are posttraumatic; 30% are idiopathic; and the remainder are due to vascular lesions, infections, systemic diseases such as sarcoidosis that affect the hypothalamus, or mutations in the gene for prepropressophysin. Disease that develops after surgical removal of the posterior lobe of the pituitary may be temporary if the distal ends of the supraoptic and paraventricular fibers are only damaged, because the fibers recover, make new vascular connections, and begin to secrete vasopressin again.
The symptoms of diabetes insipidus are passage of large amounts of dilute urine (polyuria) and the drinking of large amounts of fluid (polydipsia), provided the thirst mechanism is intact. It is the polydipsia that keeps these patients healthy. If their sense of thirst is depressed for any reason and their intake of dilute fluid decreases, they develop dehydration that can be fatal.
Another cause of diabetes insipidus is inability of the kidneys to respond to vasopressin (nephrogenic diabetes insipidus). Two forms of this disease have been described. In one form, the gene for the V2 receptor is mutated, making the receptor unresponsive. The V2 receptor gene is on the X chromosome, thus this condition is X-linked and inheritance is sex-linked recessive. In the other form of the condition, mutations occur in the autosomal gene for aquaporin-2 and produce nonfunctional versions of this water channel, many of which do not reach the apical membrane of the collecting duct but are trapped in intracellular locations.
SYNTHETIC AGONISTS & ANTAGONISTS
Synthetic peptides that have selective actions and are more active than naturally occurring vasopressin have been produced by altering the amino acid residues. For example, 1-deamino-8-D-arginine vasopressin (desmopressin; dDAVP) has very high antidiuretic activity with little pressor activity, making it valuable in the treatment of vasopressin deficiency.
DEFENSE OF VOLUME
The volume of the ECF is determined primarily by the total amount of osmotically active solute in the ECF. The composition of the ECF is discussed in Chapter 1. Because Na+ and Cl– are by far the most abundant osmotically active solutes in ECF, and because changes in Cl– are to a great extent secondary to changes in Na+, the amount of Na+ in the ECF is the most important determinant of ECF volume. Therefore, the mechanisms that control Na+ balance are the major mechanisms defending ECF volume. However, there is volume control of water excretion as well; a rise in ECF volume inhibits vasopressin secretion, and a decline in ECF volume produces an increase in the secretion of this hormone. Volume stimuli override the osmotic regulation of vasopressin secretion. Angiotensin II stimulates aldosterone and vasopressin secretion. It also causes thirst and constricts blood vessels, which help to maintain blood pressure. Thus, angiotensin II plays a key role in the body’s response to hypovolemia (Figure 38–5). In addition, expansion of the ECF volume increases the secretion of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) by the heart, and this causes natriuresis and diuresis.
FIGURE 38–5 Summary of the renin–angiotensin system and the stimulation of aldosterone secretion by angiotensin II. The plasma concentration of renin is the rate-limiting step in the renin–angiotensin system; therefore, it is the major determinant of plasma angiotensin II concentration.
In disease states, loss of water from the body (dehydration) causes a moderate decrease in ECF volume, because water is lost from both the intracellular and ECF compartments; but excessive loss of Na+ in the stools (diarrhea), urine (severe acidosis, adrenal insufficiency), or sweat (heat prostration) decreases ECF volume markedly and eventually leads to shock. The immediate compensations in shock operate principally to maintain intravascular volume, but they also affect Na+ balance. In adrenal insufficiency, the decline in ECF volume is not only due to loss of Na+ in the urine but also to its movement into cells. Because of the key position of Na+ in volume homeostasis, it is not surprising that more than one mechanism has evolved to control the excretion of this ion.
The filtration and reabsorption of Na+ in the kidneys and the effects of these processes on Na+ excretion are discussed in Chapter 37. When ECF volume is decreased, blood pressure falls, glomerular capillary pressure declines, and the glomerular filtration rate (GFR) therefore falls, reducing the amount of Na+ filtered. Tubular reabsorption of Na+ is increased, in part because the secretion of aldosterone is increased. Aldosterone secretion is controlled in part by a feedback system in which the change that initiates increased secretion is a decline in mean intravascular pressure. Other changes in Na+ excretion occur too rapidly to be solely due to changes in aldosterone secretion. For example, rising from the supine to the standing position increases aldosterone secretion. However, Na+ excretion is decreased within a few minutes, and this rapid change in Na+ excretion occurs in adrenalectomized subjects. It is probably due to hemodynamic changes and possibly to decreased ANP secretion.
The kidneys produce three hormones: 1,25-dihydroxycholecalciferol (see Chapter 21), renin, and erythropoietin. Natriuretic peptides, substances secreted by the heart and other tissues, increase excretion of sodium by the kidneys, and an additional natriuretic hormone (endogenous ouabain) inhibits Na, K ATPase.
THE RENIN–ANGIOTENSIN SYSTEM
The rise in blood pressure produced by injection of kidney extracts is due to renin, an acid protease secreted by the kidneys into the bloodstream. This enzyme acts in concert with angiotensin-converting enzyme (ACE) to form angiotensin II (Figure 38–6). It is a glycoprotein with a molecular weight of 37,326 in humans. The molecule is made up of two lobes, or domains, between which the active site of the enzyme is located in a deep cleft. Two aspartic acid residues, one at position 104 and one at position 292 (residue numbers from human preprorenin), are juxtaposed in the cleft and are essential for activity. Thus, renin is an aspartyl protease.
FIGURE 38–6 Formation and metabolism of circulating angiotensins.
Like other hormones, renin is synthesized as a large preprohormone. Human preprorenin contains 406 amino acid residues. The prorenin that remains after removal of a leader sequence of 23 amino acid residues from the amino terminal contains 383 amino acid residues, and after removal of the pro sequence from the amino terminal of prorenin, active renin contains 340 amino acid residues. Prorenin has little if any biologic activity.
Some prorenin is converted to renin in the kidneys, and some is secreted. Prorenin is also secreted by other organs, including the ovaries. After nephrectomy, the prorenin level in the circulation is usually only moderately reduced and may actually rise, but the level of active renin falls to essentially zero. Thus, very little prorenin is converted to renin in the circulation, and active renin is a product primarily, if not exclusively, of the kidneys. Prorenin is secreted constitutively, whereas active renin is formed in the secretory granules of the granular cells in the juxtaglomerular apparatus, the same cells that produce renin (see below). Active renin has a half-life in the circulation of 80 min or less. Its only known function is to cleave the decapeptide angiotensin I from the amino terminal end of angiotensinogen (renin substrate) (Figure 38–7).
FIGURE 38–7 Structure of the amino terminal end of angiotensinogen and angiotensins I, II, and III in humans. R, remainder of protein. After removal of a 24-amino-acid leader sequence, angiotensinogen contains 453 amino acid residues. The structure of angiotensin II in dogs, rats, and many other mammals is the same as that in humans. Bovine and ovine angiotensin II have valine instead of isoleucine at position 5.
Circulating angiotensinogen is found in the α2-globulin fraction of the plasma (Figure 38–6). It contains about 13% carbohydrate and is made up of 453 amino acid residues. It is synthesized in the liver with a 32-amino-acid signal sequence that is removed in the endoplasmic reticulum. Its circulating level is increased by glucocorticoids, thyroid hormones, estrogens, several cytokines, and angiotensin II.
ANGIOTENSIN-CONVERTING ENZYME & ANGIOTENSIN II
ACE is a dipeptidyl carboxypeptidase that splits off histidyl-leucine from the physiologically inactive angiotensin I, forming the octapeptide angiotensin II (Figure 38–7). The same enzyme inactivates bradykinin (Figure 38–6). Increased tissue bradykinin produced when ACE is inhibited acts on B2 receptors to produce the cough that is an annoying side effect in up to 20% of patients treated with ACE inhibitors (see Clinical Box 38–2). Most of the converting enzyme that forms angiotensin II in the circulation is located in endothelial cells. Much of the conversion occurs as the blood passes through the lungs, but conversion also occurs in many other parts of the body.
CLINICAL BOX 38–2
Pharmacologic Manipulation of the Renin–Angiotensin System
It is now possible to inhibit the secretion or the effects of renin in a variety of ways. Inhibitors of prostaglandin synthesis such as indomethacin and β-adrenergic blocking drugs such as propranolol reduce renin secretion. The peptide pepstatin and newly developed renin inhibitors such as enalkiren prevent renin from generating angiotensin I. Angiotensin-converting enzyme inhibitors (ACE inhibitors) such as captopril and enalapril prevent conversion of angiotensin I to angiotensin II. Saralasin and several other analogs of angiotensin II are competitive inhibitors of the action of angiotensin II on both AT1 and AT2 receptors. Losartan (DuP-753) selectively blocks AT1 receptors, and PD-123177 and several other drugs selectively block AT2 receptors.
ACE is an ectoenzyme that exists in two forms: a somatic form found throughout the body and a germinal form found solely in postmeiotic spermatogenic cells and spermatozoa (see Chapter 23). Both ACEs have a single transmembrane domain and a short cytoplasmic tail. However, somatic ACE is a 170-kDa protein with two homologous extracellular domains, each containing an active site (Figure 38–8). Germinal ACE is a 90-kDa protein that has only one extracellular domain and active site. Both enzymes are formed from a single gene. However, the gene has two different promoters, producing two different mRNAs. In male mice in which the ACE gene has been knocked out, blood pressure is lower than normal, but in females it is normal. In addition, fertility is reduced in males but not in females.
FIGURE 38–8 Diagrammatic representation of the structure of the somatic form of angiotensin-converting enzyme. Note the short cytoplasmic tail of the molecule and the two extracellular catalytic sites, each of which binds a zinc ion (Zn2+). (Reproduced with permission from Johnston CI: Tissue angiotensin-converting enzyme in cardiac and vascular hypertrophy, repair, and remodeling. Hypertension 1994;23:258. Copyright © 1994 by The American Heart Association.)
METABOLISM OF ANGIOTENSIN II
Angiotensin II is metabolized rapidly; its half-life in the circulation in humans is 1–2 min. It is metabolized by various peptidases. An aminopeptidase removes the aspartic acid (Asp) residue from the amino terminal of the peptide (Figure 38–7). The resulting heptapeptide has physiologic activity and is sometimes called angiotensin III. Removal of a second amino terminal residue from angiotensin III produces the hexapeptide sometimes called angiotensin IV, which is also said to have some activity. Most, if not all, of the other peptide fragments that are formed are inactive. In addition, aminopeptidase can act on angiotensin I to produce (des-Asp1) angiotensin I, and this compound can be converted directly to angiotensin III by the action of ACE. Angiotensin-metabolizing activity is found in red blood cells and many tissues. In addition, angiotensin II appears to be removed from the circulation by some sort of trapping mechanism in the vascular beds of tissues other than the lungs.
Renin is usually measured by incubating the sample to be assayed and measuring by immunoassay the amount of angiotensin I generated. This measures the plasma renin activity (PRA) of the sample. Deficiency of angiotensinogen as well as renin can cause low PRA values, and to avoid this problem, exogenous angiotensinogen is often added, so that plasma renin concentration (PRC) rather than PRA is measured. The normal PRA in supine subjects eating a normal amount of sodium is approximately 1 ng of angiotensin I generated per milliliter per hour. The plasma angiotensin II concentration in such subjects is about 25 pg/mL (approximately 25 pmol/L).
ACTIONS OF ANGIOTENSINS
Angiotensin I appears to function solely as the precursor of angiotensin II and does not have any other established action.
Angiotensin II produces arteriolar constriction and a rise in systolic and diastolic blood pressure. It is one of the most potent vasoconstrictors known, being four to eight times as active as norepinephrine on a weight basis in normal individuals. However, its pressor activity is decreased in Na+-depleted individuals and in patients with cirrhosis and some other diseases. In these conditions, circulating angiotensin II is increased, and this down-regulates the angiotensin receptors in vascular smooth muscle. Consequently, there is less response to injected angiotensin II.
Angiotensin II also acts directly on the adrenal cortex to increase the secretion of aldosterone, and the renin–angiotensin system is a major regulator of aldosterone secretion. Additional actions of angiotensin II include facilitation of the release of norepinephrine by a direct action on postganglionic sympathetic neurons, contraction of mesangial cells with a resultant decrease in GFR (see Chapter 37), and a direct effect on the renal tubules to increase Na+reabsorption.
Angiotensin II also acts on the brain to decrease the sensitivity of the baroreflex, and this potentiates the pressor effect of angiotensin II. In addition, it acts on the brain to increase water intake and increase the secretion of vasopressin and ACTH. It does not penetrate the blood–brain barrier, but it triggers these responses by acting on the circumventricular organs, four small structures in the brain that are outside the blood–brain barrier (see Chapter 33). One of these structures, the area postrema, is primarily responsible for the pressor potentiation, whereas two of the others, the subfornical organ (SFO) and the OVLT, are responsible for the increase in water intake (dipsogenic effect). It is not certain which of the circumventricular organs are responsible for the increases in vasopressin and ACTH secretion.
Angiotensin III [(des-Asp1) angiotensin II] has about 40% of the pressor activity of angiotensin II, but 100% of the aldosterone-stimulating activity. It has been suggested that angiotensin III is the natural aldosterone-stimulating peptide, whereas angiotensin II is the blood-pressure-regulating peptide. However, this appears not to be the case, and instead angiotensin III is simply a breakdown product with some biologic activity. The same is probably true of angiotensin IV, though some researchers have argued that it has unique effects in the brain.
TISSUE RENIN–ANGIOTENSIN SYSTEMS
In addition to the system that generates circulating angiotensin II, many different tissues contain independent renin–angiotensin systems that generate angiotensin II, apparently for local use. Components of the renin–angiotensin system are found in the walls of blood vessels and in the uterus, the placenta, and the fetal membranes. Amniotic fluid has a high concentration of prorenin. In addition, tissue renin–angiotensin systems, or at least several components of the renin–angiotensin system, are present in the eyes, exocrine portion of the pancreas, heart, fat, adrenal cortex, testis, ovary, anterior and intermediate lobes of the pituitary, pineal, and brain. Tissue renin contributes very little to the circulating renin pool, because PRA falls to undetectable levels after the kidneys are removed. The functions of these tissue renin–angiotensin systems are unsettled, though evidence is accumulating that angiotensin II is a significant growth factor in the heart and blood vessels. ACE inhibitors or AT1 receptor blockers are now the treatment of choice for congestive heart failure, and part of their value may be due to inhibition of the growth effects of angiotensin II.
ANGIOTENSIN II RECEPTORS
There are at least two classes of angiotensin II receptors. AT1 receptors are serpentine receptors coupled by a G protein (Gq) to phospholipase C, and angiotensin II increases the cytosolic free Ca2+ level. It also activates numerous tyrosine kinases. In vascular smooth muscle, AT1 receptors are associated with caveolae (see Chapter 2), and AII increases production of caveolin-1, one of the three isoforms of the protein that is characteristic of caveolae. In rodents, two different but closely related AT1 subtypes, AT1A and AT1B, are coded by two separate genes. The AT1A subtype is found in blood vessel walls, the brain, and many other organs. It mediates most of the known effects of angiotensin II. The AT1B subtype is found in the anterior pituitary and the adrenal cortex. In humans, an AT1 receptor gene is present on chromosome 3. There may be a second AT1 type, but it is still unsettled whether distinct AT1Aand AT1B subtypes occur.
There are also AT2 receptors, which are coded in humans by a gene on the X chromosome. Like the AT1 receptors, they have seven transmembrane domains, but their actions are different. They act via a G protein to activate various phosphatases which in turn antagonize growth effects and open K+ channels. In addition, AT2 receptor activation increases the production of NO and therefore increases intracellular cyclic 3,5-guanosine monophosphate (cGMP). The overall physiologic consequences of these second-messenger effects are unsettled. AT2 receptors are more plentiful in fetal and neonatal life, but they persist in the brain and other organs in adults.
The AT1 receptors in the arterioles and the AT1 receptors in the adrenal cortex are regulated in opposite ways: an excess of angiotensin II down-regulates the vascular receptors, but it up-regulates the adrenocortical receptors, making the gland more sensitive to the aldosterone-stimulating effect of the peptide.
THE JUXTAGLOMERULAR APPARATUS
The renin in kidney extracts and the bloodstream is produced by the juxtaglomerular cells (JG cells). These epitheloid cells are located in the media of the afferent arterioles as they enter the glomeruli (Figure 38–9). The membrane-lined secretory granules in them have been shown to contain renin. Renin is also found in agranular lacis cells that are located in the junction between the afferent and efferent arterioles, but its significance in this location is unknown.
FIGURE 38–9 Left: Diagram of glomerulus, showing the juxtaglomerular apparatus. Right: Phase contrast photomicrograph of afferent arteriole in an unstained, freeze-dried preparation of the kidney of a mouse. Note the red blood cell in the lumen of the arteriole and the granular cells in the wall. (Courtesy of C Peil.)
At the point where the afferent arteriole enters the glomerulus and the efferent arteriole leaves it, the tubule of the nephron touches the arterioles of the glomerulus from which it arose. At this location, which marks the start of the distal convolution, there is a modified region of tubular epithelium called the macula densa (Figure 38–9). The macula densa is in close proximity to the JG cells. The lacis cells, the JG cells, and the macula densa constitute the juxtaglomerular apparatus.
REGULATION OF RENIN SECRETION
Several different factors regulate renin secretion (Table 38–2), and the rate of renin secretion at any given time is determined by the summed activity of these factors. One factor is an intra-renal baroreceptor mechanism that causes renin secretion to decrease when arteriolar pressure at the level of the JG cells increases and to increase when arteriolar pressure at this level falls. Another renin-regulating sensor is in the macula densa. Renin secretion is inversely proportional to the amount of Na+ and Cl– entering the distal renal tubules from the loop of Henle. Presumably, these electrolytes enter the macula densa cells via the Na–K–2Cl– transporters in their apical membranes, and the increase in some fashion triggers a signal that decreases renin secretion in the juxtaglomerular cells in the adjacent afferent arterioles. A possible mediator is NO, but the identity of the signal remains unsettled. Renin secretion also varies inversely with the plasma K+ level, but the effect of K+ appears to be mediated by the changes it produces in Na+ and Cl– delivery to the macula densa.
TABLE 38–2 Factors that affect renin secretion.
Angiotensin II feeds back to inhibit renin secretion by a direct action on the JG cells. Vasopressin also inhibits renin secretion in vitro and in vivo, although there is some debate about whether its in vivo effect is direct or indirect.
Finally, increased activity of the sympathetic nervous system increases renin secretion. The increase is mediated both by increased circulating catecholamines and by norepinephrine secreted by postganglionic renal sympathetic nerves. The catecholamines act mainly on β1-adrenergic receptors on the JG cells and renin release is mediated by an increase in intracellular cAMP.
The principal conditions that increase renin secretion in humans are listed in Table 38–3. Most of the listed conditions decrease central venous pressure, which triggers an increase in sympathetic activity, and some also decrease renal arteriolar pressure (see Clinical Box 38–3). Renal artery constriction and constriction of the aorta proximal to the renal arteries produces a decrease in renal arteriolar pressure. Psychologic stimuli increase the activity of the renal nerves.
TABLE 38–3 Conditions that increase renin secretion.
CLINICAL BOX 38–3
Role of Renin in Clinical Hypertension
Constriction of one renal artery causes a prompt increase in renin secretion and the development of sustained hypertension (renal or Goldblatt hypertension). Removal of the ischemic kidney or the arterial constriction cures the hypertension if it has not persisted too long. In general, the hypertension produced by constricting one renal artery with the other kidney intact (one-clip, two-kidney Goldblatt hypertension) is associated with increased circulating renin. The clinical counterpart of this condition is renal hypertension due to atheromatous narrowing of one renal artery or other abnormalities of the renal circulation. However, plasma renin activity is usually normal in one-clip one-kidney Goldblatt hypertension. The explanation of the hypertension in this situation is unsettled. However, many patients with hypertension respond to treatment with ACE inhibitors or losartan even when their renal circulation appears to be normal and they have normal or even low plasma renin activity.
HORMONES OF THE HEART & OTHER NATRIURETIC FACTORS
The existence of various natriuretic hormones has been postulated for some time. Two of these are secreted by the heart. The muscle cells in the atria and, to a much lesser extent in the ventricles, contain secretory granules (Figure 38–10). The granules increase in number when NaCl intake is increased and ECF expanded, and extracts of atrial tissue cause natriuresis.
FIGURE 38–10 ANP granules (g) interspersed between mitochondria (m) in rat atrial muscle cell. G, Golgi complex; N, nucleus. The granules in human atrial cells are similar (× 17,640). (Courtesy of M Cantin.)
The first natriuretic hormone isolated from the heart was ANP, a polypeptide with a characteristic 17-amino-acid ring formed by a disulfide bond between two cysteines. The circulating form of this polypeptide has 28 amino acid residues (Figure 38–11). It is formed from a large precursor molecule that contains 151 amino acid residues, including a 24-amino-acid signal peptide. ANP was subsequently isolated from other tissues, including the brain, where it exists in two forms that are smaller than circulating ANP. A second natriuretic polypeptide was isolated from porcine brain and named brain natriuretic peptide (BNP; also known as B-type natriuretic peptide). It is also present in the brain in humans, but more is present in the human heart, including the ventricles. The circulating form of this hormone contains 32 amino acid residues. It has the same 17-member ring as ANP, though some of the amino acid residues in the ring are different (Figure 38–11). A third member of this family has been named C-type natriuretic peptide (CNP) because it was the third in the sequence to be isolated. It contains 22 amino acid residues (Figure 38–11), and there is also a larger 53-amino-acid form. CNP is present in the brain, the pituitary, the kidneys, and vascular endothelial cells. However, very little is present in the heart and the circulation, and it appears to be primarily a paracrine mediator.
FIGURE 38–11 Human ANP, BNP, and CNP. Top: Single-letter codes for amino acid residues aligned to show common sequences (colored). Bottom: Shape of molecules. Note that one cysteine is the carboxyl terminal amino acid residue in CNP, so there is no carboxyl terminal extension from the 17-member ring. (Modified from Imura H, Nakao K, Itoh H: The natriuretic peptide system in the brain: Implication in the central control of cardiovascular and neuroendocrine functions. Front Neuroendocrinol 1992;13:217.)
ANP and BNP in the circulation act on the kidneys to increase Na+ excretion and injected CNP has a similar effect. They appear to produce this effect by dilating afferent arterioles and relaxing mesangial cells. Both of these actions increase glomerular filtration (see Chapter 37). In addition, they act on the renal tubules to inhibit Na+ reabsorption (see Chapter 37). Other actions include an increase in capillary permeability, leading to extravasation of fluid and a decline in blood pressure. In addition, they relax vascular smooth muscle in arterioles and venules. CNP has a greater dilator effect on veins than ANP and BNP. These peptides also inhibit renin secretion and counteract the pressor effects of catecholamines and angiotensin II.
In the brain, ANP is present in neurons, and an ANP-containing neural pathway projects from the anteromedial part of the hypothalamus to the areas in the lower brain stem that are concerned with neural regulation of the cardiovascular system. In general, the effects of ANP in the brain are opposite to those of angiotensin II, and ANP-containing neural circuits appear to be involved in lowering blood pressure and promoting natriuresis. CNP and BNP in the brain probably have functions similar to those of ANP, but detailed information is not available.
NATRIURETIC PEPTIDE RECEPTORS
Three different natriuretic peptide receptors (NPR) have been isolated and characterized (Figure 38–12). The NPR-A and NPR-B receptors both span the cell membrane and have cytoplasmic domains that are guanylyl cyclases. ANP has the greatest affinity for the NPR-A receptor, and CNP has the greatest affinity for the NPR-B receptor. The third receptor, NPR-C, binds all three natriuretic peptides but has a markedly truncated cytoplasmic domain. Some evidence suggests that it acts via G proteins to activate phospholipase C and inhibit adenylyl cyclase. However, it has also been argued that this receptor does not trigger any intracellular change and is instead a clearance receptorthat removes natriuretic peptides from the bloodstream and then releases them later, helping to maintain a steady blood level of the hormones.
FIGURE 38–12 Diagrammatic representation of natriuretic peptide receptors. The NPR-A and NPR-B receptor molecules have intracellular guanylyl cyclase domains, whereas the putative clearance receptor, NPR-C, has only a small cytoplasmic domain. CM, cell membrane.
SECRETION & METABOLISM
The concentration of ANP in plasma is about 5 fmol/mL in normal humans ingesting moderate amounts of NaCl. ANP secretion is increased when the ECF volume is increased by infusion of isotonic saline and when the atria are stretched. BNP secretion is increased when the ventricles are stretched. ANP secretion is also increased by immersion in water up to the neck (Figure 38–13), a procedure that counteracts the effect of gravity on the circulation and increases central venous and consequently atrial pressure. Note that immersion also decreases the secretion of renin and aldosterone. Conversely, a small but measurable decrease in plasma ANP occurs in association with a decrease in central venous pressure on rising from the supine to the standing position. Thus, it seems clear that the atria respond directly to stretch in vivo and that the rate of ANP secretion is proportional to the degree to which the atria are stretched by increases in central venous pressure. Similarly, BNP secretion is proportional to the degree to which the ventricles are stretched. Plasma levels of both hormones are elevated in congestive heart failure, and their measurement is seeing increasing use in the diagnosis of this condition.
FIGURE 38–13 Effect of immersion in water up to the neck for 3 h on plasma concentrations of ANP, PRA, and aldosterone. (Modified and reproduced with permission from Epstein M, et al: Increases in circulating atrial natriuretic factor during immersion-induced central hypervolaemia in normal humans. J Hypertension Suppl 1986 June;4(2):S93–S99.)
Circulating ANP has a short half-life. It is metabolized by neutral endopeptidase (NEP), which is inhibited by thiorphan. Therefore, administration of thiorphan increases circulating ANP.
Na, K ATPase-INHIBITING FACTOR
Another natriuretic factor is present in blood. This factor produces natriuresis by inhibiting Na, K ATPase and raises rather than lowers blood pressure. Current evidence indicates that it may well be the digitalis-like steroid ouabainand that it comes from the adrenal glands. However, its physiologic significance is not yet known.
DEFENSE OF SPECIFIC IONIC COMPOSITION
Special regulatory mechanisms maintain the levels of certain specific ions in the ECF as well as the levels of glucose and other nonionized substances important in metabolism (see Chapter 1). The feedback of Ca2+ on the parathyroids and the calcitonin-secreting cells to adjust their secretion maintains the ionized calcium level of the ECF (see Chapter 21). The Mg2+ concentration is subject to close regulation, but the mechanisms controlling Mg+homeostasis are incompletely understood.
The mechanisms controlling Na+ and K+ content are part of those determining the volume and tonicity of ECF and have been discussed above. The levels of these ions are also dependent on the H+ concentration, and pH is one of the major factors affecting the anion composition of ECF. This will be discussed in Chapter 39.
STRUCTURE & FUNCTION
When an individual bleeds or becomes hypoxic, hemoglobin synthesis is enhanced, and production and release of red blood cells from the bone marrow (erythropoiesis) are increased (see Chapter 31). Conversely, when the red cell volume is increased above normal levels by transfusion, the erythropoietic activity of the bone marrow decreases. These adjustments are brought about by changes in the circulating level of erythropoietin, a circulating glycoprotein that contains 165 amino acid residues and four oligosaccharide chains that are necessary for its activity in vivo. Its blood level is markedly increased in anemia (Figure 38–14).
FIGURE 38–14 Plasma erythropoietin levels in normal blood donors (triangles) and patients with various forms of anemia (squares). (Reproduced with permission from Erslev AJ: Erythropoietin. N Engl J Med 1991;324:1339.)
Erythropoietin increases the number of erythropoietin-sensitive committed stem cells in the bone marrow that are converted to red blood cell precursors and subsequently to mature erythrocytes (see Chapter 31). The receptor for erythropoietin is a linear protein with a single transmembrane domain that is a member of the cytokine receptor superfamily (see Chapter 3). The receptor has tyrosine kinase activity, and it activates a cascade of serine and threonine kinases, resulting in inhibited apoptosis of red cells and their increased growth and development.
The principal site of inactivation of erythropoietin is the liver, and the hormone has a half-life in the circulation of about 5 h. However, the increase in circulating red cells that it triggers takes 2–3 days to appear, since red cell maturation is a relatively slow process.
In adults, about 85% of the erythropoietin comes from the kidneys and 15% from the liver. Both these organs contain the mRNA for erythropoietin. Erythropoietin can also be extracted from the spleen and salivary glands, but these tissues do not contain its mRNA and consequently do not appear to manufacture the hormone. When renal mass is reduced in adults by renal disease or nephrectomy, the liver cannot compensate and anemia develops.
Erythropoietin is produced by interstitial cells in the peritubular capillary bed of the kidneys and by perivenous hepatocytes in the liver. It is also produced in the brain, where it exerts a protective effect against excitotoxic damage triggered by hypoxia; and in the uterus and oviducts, where it is induced by estrogen and appears to mediate estrogen-dependent angiogenesis.
The gene for the hormone has been cloned, and recombinant erythropoietin produced in animal cells is available for clinical use as epoetin alfa. The recombinant erythropoietin is of value in the treatment of the anemia associated with renal failure; 90% of the patients with end-stage renal failure who are on dialysis are anemic as a result of erythropoietin deficiency. Erythropoietin is also used to stimulate red cell production in individuals who are banking a supply of their own blood in preparation for autologous transfusions during elective surgery (see Chapter 31).
REGULATION OF SECRETION
The usual stimulus for erythropoietin secretion is hypoxia, but secretion of the hormone can also be stimulated by cobalt salts and androgens. Recent evidence suggests that the O2 sensor regulating erythropoietin secretion in the kidneys and the liver is a heme protein that in the deoxy form stimulates and in the oxy form inhibits transcription of the erythropoietin gene to form erythropoietin mRNA. Secretion of the hormone is also facilitated by the alkalosis that develops at high altitudes. Like renin secretion, erythropoietin secretion is facilitated by catecholamines via a β-adrenergic mechanism, although the renin–angiotensin system is totally separate from the erythropoietin system.
Total body osmolality is directly proportional to the total body sodium plus the total body potassium divided by the total body water. Changes in the osmolality of the body fluids occur when a disproportion exists between the amount of these electrolytes and the amount of water ingested or lost from the body.
Vasopressin’s main physiologic effect is the retention of water by the kidney by increasing the water permeability of the renal collecting ducts. Water is absorbed from the urine, the urine becomes concentrated, and its volume decreases.
Vasopressin is stored in the posterior pituitary and released into the bloodstream in response to the stimulation of osmoreceptors or baroreceptors. Increases in secretion occur when osmolality is changed as little as 1%, thus keeping the osmolality of the plasma very close to 285 mOsm/L.
The amount of Na+ in the ECF is the most important determinant of ECF volume, and mechanisms that control Na+ balance are the major mechanisms defending ECF volume. The main mechanism regulating sodium balance is the renin–angiotensin system, a hormone system that regulates blood pressure.
The kidneys secrete the enzyme renin and renin acts in concert with angiotensin-converting enzyme to form angiotensin II. Angiotensin II acts directly on the adrenal cortex to increase the secretion of aldosterone. Aldosterone increases the retention of sodium from the urine via action on the renal collecting duct.
For all questions, select the single best answer unless otherwise directed.
1. Dehydration increases the plasma concentration of all the following hormones except
B. angiotensin II.
E. atrial natriuretic peptide.
2. In a patient who has become dehydrated, body water should be replaced by intravenous infusion of
A. distilled water.
B. 0.9% sodium chloride solution.
C. 5% glucose solution.
D. hyperoncotic albumin.
E. 10% glucose solution.
3. Renin is secreted by
A. cells in the macula densa.
B. cells in the proximal tubules.
C. cells in the distal tubules.
D. granular cells in the juxtaglomerular apparatus.
E. cells in the peritubular capillary bed.
4. Erythropoietin is secreted by
A. cells in the macula densa.
B. cells in the proximal tubules.
C. cells in the distal tubules.
D. granular cells in the juxtaglomerular apparatus.
E. cells in the peritubular capillary bed.
5. When a woman who has been on a low-sodium diet for 8 days is given an intravenous injection of captopril, a drug that inhibits angiotensin-converting enzyme, one would expect
A. her blood pressure to rise because her cardiac output would fall.
B. her blood pressure to rise because her peripheral resistance would fall.
C. her blood pressure to fall because her cardiac output would fall.
D. her blood pressure to fall because her peripheral resistance would fall.
E. her plasma renin activity to fall because her circulating angiotensin I level would rise.
6. Which of the following would not be expected to increase renin secretion?
A. Administration of a drug that blocks angiotensin-converting enzyme
B. Administration of a drug that blocks AT1 receptors
C. Administration of a drug that blocks β-adrenergic receptors
D. Constriction of the aorta between the celiac artery and the renal arteries
E. Administration of a drug that reduces ECF volume
7. Which of the following is least likely to contribute to the beneficial effects of angiotensin-converting enzyme inhibitors in the treatment of congestive heart failure?
B. Decreased cardiac growth
C. Decreased cardiac afterload
D. Increased plasma renin activity
E. Decreased plasma aldosterone
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