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ducts Consider how this affects the medullary osmotic gradient When a person is dehydrated, glomerular filtration rate (GFR) is somewhat low and levels of ADH are high The extraction of water in the cortical collecting duct removes most of the water from the lumen (and makes it iso-osmotic with the cortical interstitium ie, about 300 mOsm/kg) Then, as the remaining but greatly reduced, volume flows through the high osmolality medulla, further concentration occurs The increased urea permeability signaled by ADH greatly assists in generating the medullary osmotic gradient by permitting the recycling of urea Contrast this with a state of overhydration as after a beverage drinking contest Some of the medullary solute is washed out and the magnitude of the osmotic gradient is reduced How does this occur In states of overhydration levels of ADH are low GFR is substantial Only a small amount of the tubular fluid entering the cortical collecting ducts is reabsorbed Therefore, tubular urea does not become concentrated very much A high volume of very dilute fluid with a modest urea concentration is delivered to the inner medullary collecting ducts In contrast to the cortical and outer medullary collecting ducts, which are nearly water impermeable in the absence of ADH, the inner medullary collecting duct has a finite water permeability in the absence of ADH Although this water permeability is not large, the osmotic driving force is huge, so substantial amounts of water are reabsorbed (However, even more is not reabsorbed, and so the urine volume is still very large) Not much urea is reabsorbed; in fact, it may be secreted initially because the luminal urea concentration is lower than in the medullary interstitium The result of the water reabsorption and the low (or absent) urea reabsorption is that the inner medulla is partially diluted (ie, the urea concentration and total osmolality of the medullary interstitium decrease over time) The osmolality falls to about half of its value, from well over 1000 mOsm/kg down to 500 600 mOsm/kg (Table 6 5) A major factor contributing to the washout is an increase
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Table 6 5 Composition of medullary interstitial fluid and urine during the formation of a concentrated urine or a dilute urine
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Interstitial fluid at tip of medulla (mOsm/L) Concentrated urine Urea 5 650 Na+ + Cl 5 750a Urea 5 700 Nonurea solutes 5 700 (Na+, Cl , K+, urate, creatinine, etc) Dilute urine Urea 5 300 Na+ + Cl 5 350a
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Urine (mOsm/L)
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Urea 5 30 60 Nonurea solutes 5 10 40 (Na+, Cl , K+, urate, creatinine, etc)b
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Some other ions (eg, K1) contribute to a small degree to this osmolarity Depending on the sodium balance state, sodium in the urine can vary between undetectable and the majority of the osmolytes
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BasiC renal proCesses for sodium, Chloride, and Water / 99
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in medullary blood flow, due in part to removal of the vasoconstricting action of ADH Figure 6 6 depicts renal water fluxes in the two extremes of maximum diuresis and antidiuresis Let us conclude this chapter by addressing two issues that often confuse students First, one might expect that under conditions of high ADH, there should be even more water reabsorbed from the medullary collecting ducts than there is with low ADH, and that this water would dilute the interstitium and abolish the osmotic gradient Water does enter the medullary interstitium from medullary collecting ducts aided by the actions of ADH, but so little water remains in the tubule after passage through the cortex that the amount remaining to be reabsorbed is quite small Also, as described earlier, water enters from descending thin limbs of the loops of Henle and from descending vasa recta Although there is a tendency for all of this water to dilute the interstitium, there is also a continuing deposition of new solute by the thick ascending limb The competing tendencies to dilute the interstitium with water and to concentrate the interstitium with salt reach a balance in which osmolality is high It is this balance that sets the upper limit on medullary osmolality Another issue that appears paradoxical concerns medullary water reabsorption during diuresis when ADH is low and the body is excreting large amounts of water In this condition, more water is reabsorbed in the medulla than during antidiuresis when ADH is high and the body is conserving water This seeming paradox is resolved by realizing that during diuresis there is little cortical water
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Osmolarity (mOsm/L)
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