Koeppen BM. The kidney and acid-base regulation. Adv Physiol dietary perspective, fruits and vegetables result in the genera-
Educ 33: 275–281, 2009; doi:10.1152/advan.00054.2009.—Since the tion of alkali, whereas meat, grains, and dairy products gener-
topic of the role of the kidneys in the regulation of acid-base balance ate acid. In addition, the diet may contain various acids and
was last reviewed from a teaching perspective (Koeppen BM. Renal alkalis that, when absorbed via the gastrointestinal tract, con-
regulation of acid-base balance. Adv Physiol Educ 20: 132–141,
1998), our understanding of the specific membrane transporters in-
tribute to the net acid/alkali load to the body. Finally, each day,
volved in H⫹, HCO⫺ ⫹ HCO⫺ 3 is lost in the feces and thus imparts an acid load to the
3 , and NH4 transport, and especially how these
body. In a healthy individual consuming a “typical Western
TA
The H⫹ secreted into the tubular fluid can drive the reab-
sorption of the filtered load of HCO⫺ 3 as just described. In
addition, the secreted H⫹ can combine with other luminal
constituents (termed urinary buffers), such as phosphate:
alkalosis. Most of our understanding of the adaptive response receptor, both NHE3 and NBCe1 are phosphorylated, which
of the kidneys to acid-base disorders has come from using then leads to their insertion into the apical and basolateral
models of metabolic acidosis. The following section describes membranes, respectively. Cortisol secretion by the adrenal
our current understanding of how RNAE increases in this cortex is also stimulated by acidosis. Cortisol increases the
setting. abundance of NHE3 and NBCe1 in proximal tubule cells by
With acidosis RNAE increases. This response includes a increasing both mRNA levels and translation. Less is know
reduction, if not elimination, of all HCO⫺ 3 from the urine and about the effects of ET-1 and cortisol on distal H⫹ and HCO⫺ 3
increases in TA and NH⫹ 4 excretion. The key elements of this transport, although it is likely that they play a role in stimu-
response include the stimulation of H⫹ and HCO⫺ 3 transport lating key acid-base transporters in these segments as well.
along the nephron, increased ammoniagenesis, and increased Acidosis also stimulates the secretion of parathyroid hor-
availability of urinary buffers (i.e., phosphate). mone (PTH). The increased levels of PTH act on the proximal
Acidosis can directly reduce the intracellular pH of renal tubule to inhibit phosphate reabsorption. In this way, more
tubular cells. This cellular acidosis has been shown to stimulate phosphate is delivered to the distal nephron, where it can serve
NHE3 activity via allosteric mechanisms, change transporter as a urinary buffer and thus increase the capacity of the kidneys
kinetics due to altered H⫹ gradients across membranes, and to excrete TA.
cause exocytotic insertion of transporters into the plasma Ammoniagenesis by the proximal tubule is stimulated by
membrane from intracellular stores (e.g., H⫹-ATPase and acidosis. This is in part an effect of intracellular acidosis and
NHE3). It is uncertain as whether these effects of intracellular also reflects a stimulatory effect of cortisol. As already
acidosis are mediated by pH alone or secondary to the activa- noted above, acidosis increases the abundance of RhCG in
tion of intracellular regulatory pathways or mechanisms. How- the collecting duct, thus facilitating the secretion and ulti-
ever, it is now clear that other factors also mediate the renal mate excretion of NH⫹ 4 . Thus, ammoniagenesis and NH 4
⫹
response to acidosis. For example, endothelin-1 (ET-1) and excretion are stimulated.
glucocorticoids clearly play a role in the stimulation of renal Figure 8 shows our current understanding of the response of
H⫹ and HCO⫺ 3 transport during acidosis. the kidneys to acidosis. H⫹ and HCO⫺ 3 transport are increased
ET-1 is produced by both endothelial cells and proximal along the nephron. This results from a decrease in intracellular
tubule cells in response to acidosis. Acting through the ETB pH as well as effects of ET-1 and cortisol. Ammoniagenesis
and collecting duct secretion of NH⫹ 4 are stimulated. Finally, HCO⫺ 3 through the titration of urinary buffers (e.g., phosphate)
proximal tubule phosphate reabsorption is inhibited, allowing and increased excretion of NH⫹ 4 . The opposite would occur
the greater excretion of TA. The net effect is enhanced RNAE. with an expansion of ECF volume.
The most important component of the renal response to Hypo- and hyperkalemia also alter proximal tubule HCO⫺ 3
acidosis is the ability of the kidney to increase ammoniagenesis reabsorption and ammoniagenesis (hypokalemia stimulates
and NH⫹ 4 excretion. In the setting of acidosis, it is often useful both, whereas hyperkalemia has the opposite effect). The
to calculate the urinary net charge (UNC): mechanisms involved are not known with certainty but may be
linked to changes in intracellular pH. Hypokalemia also in-
UNC ⫽ 共关Na⫹兴 ⫹ 关K⫹兴兲 ⫺ 关Cl⫺兴 (6)
creases the expression of H⫹-K⫹-ATPase in the intercalated
The concept of UNC assumes that the principle urine cations in cells of the collecting duct; this, in turn, stimulates H⫹ secre-
this setting are Na⫹, K⫹, and NH⫹ 4 (not measured), and,
tion.
because urinary HCO⫺ 3 excretion is essentially zero, the prin-
ciple urine anion is Cl⫺. Thus, with acidosis, UNC as calcu- Summary
lated by Eq. 6 should have a negative value, reflecting the
excretion of NH⫹ The role of the kidneys in the acid-base balance is to excrete
4 . Indeed, a value of zero or a positive value
in this setting would be indicative of a defect in NH⫹ 4 excre-
net acid (RNAE) at an amount equal to daily NEAP. In so
tion. doing, the kidneys generate “new HCO⫺ 3 ” to replace the HCO3
⫺
The response of the kidneys to alkalosis is less well studied. lost in the titration of net endogenous acids. RNAE reflects the
Clearly, RNAE is reduced as a result of increased HCO⫺ 3
transport of H⫹ and HCO⫺ 3 by the cells of the nephron, which,
excretion and reduced excretion of NH⫹ 4 and TA. In general,
in turn, serves to reabsorb the filtered load of HCO⫺ 3 , excrete
this response is often said to reflect a reduction in those factors TA, acidify the urine, and excrete NH⫹ 4.
that are known to stimulate H⫹ and HCO⫺ 3 transport, and
ammoniagenesis as seen in the response to acidosis.
ACKNOWLEDGMENTS 6. Koeppen BM, Stanton BA. Renal Physiology (4th ed.). St. Louis, MO:
Mosby, 2007.
This work has been previously presented at the American Physiological
6a.Koeppen BM, Stanton BA. Berne and Levy Physiology (6th ed.). St.
Society’s Renal Physiology Refresher Course on April 18, 2009, in New
Louis: Mosby, 2008, p. 638 – 640, 642– 643.
Orleans, LA.
7. Oh MS, Carroll HJ. External balance of electrolytes and acids and
alkalis. In: Seldin and Giebisch’s The Kidney (4th ed.), edited by Alpern
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