Diuretic Drugs

Chapter 21 Diuretic Drugs


































Abbreviations
ATP Adenosine triphosphate
ECF Extracellular fluid
ENaC Epithelial Na+ channel
GFR Glomerular filtration rate
GI Gastrointestinal
IV Intravenous
NCC Na+/Cl cotransporter protein
NHE3 Na+/H+ exchange (antiport) protein
NKCC2 Na+/K+/2Cl cotransporter protein


Therapeutic Overview


The term diuretic classically refers to an agent that increases the rate of urine flow. However, on the basis of this definition, water is a diuretic because its ingestion is followed by an enhanced rate of urine production. Nevertheless, the diuresis induced by water is not accompanied by a substantial increase in the excretion of electrolytes, which distinguishes it from the effects of the agents described in this chapter. The primary effect of diuretics is an increase in solute excretion, mainly Na+ salts. The increase in urine flow is secondary and is a response to the osmotic force of the additional solute within the tubule lumen. Drugs that increase the net urinary excretion of Na+ salts are called natriuretics.


Despite variations in dietary salt intake, the kidneys adjust the excretion of Na+ and water to maintain the extracellular fluid (ECF) volume within narrow limits. In pathophysiological states, a deleterious expansion of the ECF leads to edema, characteristic of congestive heart failure, cirrhosis of the liver, nephrotic syndrome, and renal failure. Dietary Na+ restriction is the mainstay of treatment; however, frequently, ECF expansion persists and diuretic drugs are needed. The prevalence of edema-forming states in clinical medicine has led to the widespread use of diuretics to enhance excretion of salts (mainly NaCl) and water.


Diuretics are used in treatment of edema to normalize the volume of the ECF compartment without distorting electrolyte concentrations. The size of the ECF compartment is largely determined by the total body content of Na+, which, in turn, is determined by the balance between dietary intake and excretion. When Na+ accumulates faster than it is excreted, ECF volume expands. Conversely, when Na+ is lost faster than it is ingested, ECF volume will be depleted. Diuretics produce a transient natriuresis and reduce total body content of Na+ and the volume of the ECF. The effect is moderated, however, after 1 to 2 days, when a new equilibrium is attained. At this time a balance between intake and excretion is achieved, and body weight stabilizes. This “braking” phenomenon, in which there is refractoriness to effects of the diuretic, is


not a true tolerance but results from activation of compensatory salt-retaining mechanisms. Specifically, contraction of the ECF volume activates the sympathetic nervous system (see Chapter 19), with a resultant increase in release of angiotensin II, aldosterone, and antidiuretic hormone that may lead to a compensatory increase in Na+ reabsorption. Moreover, continued delivery of Na+ to more distal nephron segments induced by loop diuretics,





















































Therapeutic Overview
Goal: To increase excretion of salt and water
Thiazide Diuretics K+-sparing Diuretics
Hypertension Chronic liver failure
Congestive heart failure (mild) Congestive heart failure, when hypokalemia is a problem
Renal calculi Carbonic Anhydrase Inhibitors
Nephrogenic diabetes insipidus Cystinuria (to alkalinize tubular urine)
Chronic renal failure (as an adjunct to loop diuretic) Glaucoma (to decrease intraocular pressure)
Osteoporosis Periodic paralysis that affects muscle membrane function
Loop Diuretics Acute mountain sickness (to counteract respiratory alkalosis)
Hypertension, in patients with impaired renal function Metabolic alkalosis
Congestive heart failure (moderate to severe) Osmotic Diuretics
Acute pulmonary edema Acute or incipient renal failure
Chronic or acute renal failure Reduce intraocular or intracranial pressure (preoperatively)
Nephrotic syndrome  
Hyperkalemia  
Chemical intoxication (to increase urine flow)  

and its compensatory reabsorption, may lead to structural hypertrophy of these cells, thereby enhancing Na+ reabsorption.


In addition to the treatment of edema, diuretics are also efficacious in other disorders including hypertension, nephrogenic diabetes insipidus, hyponatremia, nephrolithiasis, hypercalcemia, and glaucoma. The therapeutic applications of these compounds are presented in the Therapeutic Overview Box.



Mechanisms of Action


All diuretics promote natriuresis and diuresis to reduce ECF volume; however, their mechanisms and sites of action differ. The five major types of diuretics are listed in Table 21-1, and their primary sites of action on the nephron are depicted in Figure 21-1. Knowledge of the mechanisms and sites of action of these agents is important in selecting an appropriate drug and anticipating and preventing complications. In addition, because each class of drugs exerts effects at specific targets, a combination of two or more drugs will often result in additive or synergistic effects to affect the reabsorption or excretion of Na+, Cl, image, water, and, to some extent, K+, H+, and organic ions. To understand the mechanisms and consequences of the actions of the diuretics, a basic knowledge of renal physiology is essential.










Renal Function and Regulation



Renal Epithelial Transport and Nephron Function


The normal human glomerular filtration rate (GFR) is approximately 180 L/day. Assuming a normal plasma Na+ concentration of 140 mmol/L, that means that 25,200 mmol of Na+ are filtered each day. To maintain Na+ balance, the kidney must reabsorb more than 99% (24,950 mmol) of the filtered load of Na+. This staggering amount of solute and water reabsorption is achieved by the actions of the million nephrons in each human kidney. Renal epithelial cells transport solute and water from the apical cell membrane to the basolateral cell membrane. The polarization of structures that differentiate the apical membrane from the basolateral membrane allows the vectorial transport of solute and water (Fig. 21-2). The basolateral cell membrane expresses the ubiquitous Na+/K+-adenosine triphosphatase (ATPase) (the Na+ pump) that exchanges 3 Na+ ions for 2 K+ ions, resulting in decreased intracellular Na+ providing a chemical gradient and an electronegative cell interior for Na+ entry from the lumen through the apical membrane (a potential difference of approximately 60 mV), which also attracts Na+. The concentration gradient then favors passive efflux of the K+ that entered the cell to the intercellular space. Because the ECF concentration of K+ is low relative to Na+, a recycling of K+ between the cell and interstitial fluid is necessary to maintain the Na+ pump.



The transport of Na+ across the apical cell membrane adjacent to the tubular fluid is achieved by passive diffusion via proteins that form a pore or channel (see Fig. 21-2, A), and two types of carrier-mediated transport, a cotransport (symport) pathway that transports Na+ and another solute species (such as Cl or amino acids) in the same direction (see Fig. 21-2, B), and a countertransport (antiport) pathway that transports Na+ and another solute species (H+) in the opposite direction (see Fig. 21-2, C). In each case the low intracellular Na+ concentration as a consequence of the action of the Na+/K+-ATPase pump provides the electrochemical gradient for Na+ entry.


This transepithelial transport causes the osmolality of the lateral intercellular spaces to increase as a result of the accumulation of solute, producing an osmotic gradient that permits water to flow by two routes (see Fig. 21-2):




In the primary pathway of water flow, water moves from lumen to cell to interstitial fluid to capillary, as a direct result of the transepithelial osmotic gradient.



Tubular Reabsorption: Transport by the Proximal Tubule


The GFR of healthy adults ranges from 1.7 to 1.8 mL/min/kg, and approximately two thirds of the water and NaCl filtered at the glomerulus is reabsorbed by the proximal tubule. image, glucose, amino acids, and other organic solutes are also reabsorbed. When GFR increases, salt and water excretion increases, but fractional reabsorption in the proximal tubule does not change. This is termed glomerulotubular balance. It moderates but does not entirely eliminate the effects of alterations in the GFR on salt and water excretion.


The transport of Na+, image, and Cl is important for the actions of several diuretics on the proximal tubule. Na+ is reabsorbed primarily with image in the early proximal tubule, whereas Na+ is reabsorbed primarily with Cl in the late proximal tubule (Fig. 21-3). At the apical cell membrane of the early proximal tubule, Na+ entry is coupled with H+ efflux via the Na+/H+ antiporter (NHE3), which is a protein containing 10 to 12 transmembrane spanning domains and a hydrophilic C-terminal domain and is subject to regulation by a variety of factors, including angiotensin II, which increases its activity. H+ extruded from the cell combines with image to form H2CO3, which rapidly forms CO2 and water in the presence of the enzyme carbonic anhydrase. CO2 rapidly enters the cell via simple diffusion and is rehydrated to form carbonic acid. Because the concentration of cellular H+ is low, the reaction proceeds as follows: CO2 + H2O → H2CO3 → H+ + image. Thus a constant supply of H+ is furnished for countertransport with Na+. image that accumulates is cotransported with Na+ across the basolateral cell membrane into the interstitial fluid and, subsequently, into the blood. Although the cytoplasmic hydration reaction occurs spontaneously, the rate is inadequate to allow reabsorption of the image load filtered (approximately 4000 mEq/day). However, little or none of the filtered image is excreted because of the presence of carbonic anhydrase. The net effect of coupling of the Na+/H+ antiporter to the carbonic anhydrase-mediated hydration and rehydration of CO2 is preservation of image. The final step is its transfer from the interstitial fluid into peritubular capillaries.



In the late proximal tubule (see Fig. 21-3), Na+ is reabsorbed primarily with Cl. Reabsorption is secondary to activation of both the NHE3, which couples inward Na+ transport with outward H+ transport, and a Cl base (formate) exchanger that transports Cl from lumen to cell in exchange for a base. The parallel operation of both exchangers results in net Na+ and Cl absorption by the late proximal tubule. Passive transport of Na+ and Cl also occurs between cells through the paracellular pathway.


Reabsorptive transport systems of the proximal tubule deliver large amounts of fluid and solutes to the interstitial space, which raises pressure in the interstitium. For reabsorption to continue, pressure must be decreased. The permeable peritubular capillary can easily carry away reabsorbed fluids and solutes. Pushed by interstitial pressure and pulled by the oncotic pressure of intracapillary proteins (higher in postglomerular than in preglomerular capillaries), filtered fluid and solutes return to the blood.


In summary, the proximal tubule reabsorbs approximately 70% of filtered water, Na+, and Cl, 85% of filtered image, and 50% of filtered K+ (Table 21-2). These percentages are relatively constant, even when filtered quantities increase or decrease. As a result, minor fluctuations in GFR do not influence fluid and electrolyte excretion very much. The driving force for reabsorption of water and electrolytes is the Na+/K+-ATPase. Passive movements of other ions and water are initiated and sustained by active transport of Na+ across basolateral cell membranes. Osmotic equilibrium with plasma is maintained to the end of the proximal tubule. Most of the filtered image is not actually reabsorbed directly from the lumen; rather, it is converted to CO2 and water in the vicinity of the brush border membranes, within which large concentrations of carbonic anhydrase are located. The direction of this reaction is H2CO3 → CO2 + H2O (established by the high concentration of carbonic acid in luminal fluid resulting from the secretion of H+). Carbonic anhydrase in the cytoplasm catalyzes formation of carbonic acid. Cellular H+ is then exchanged for luminal Na+, and image is reabsorbed across the basolateral cell membranes. In this indirect way, filtered image is reabsorbed.




Tubular Reabsorption: Transport by the Loop of Henle


Diuretics have no discernible actions in the descending limb of the loop of Henle. These cells permit water to diffuse from the lumen to the medullary interstitium, where higher osmotic pressures are encountered, but they do not contain specialized transport systems and are relatively impermeable to Na+ and Cl.


In contrast, the thick ascending limb and its transport functions are an important site of action of the loop (also called high-ceiling) diuretics (Fig. 21-4). Approximately 25% to 35% of filtered Na+ and Cl is reabsorbed by the loop of Henle. The Na+/K+-ATPase in the basolateral membrane provides the gradient for Na+ and Cl absorption. Na+ entry across the apical membrane is mediated by an electroneutral transport protein that binds one Na+, one K+, and two Cl ions and is referred to as the Na+/K+/2Cl (NKCC2) cotransporter. Although the ascending limb is highly permeable to Na+, K+, and Cl, it is impermeable to water. Thus the continuous reabsorption of these ions without reabsorption of water dilutes the luminal fluid, thus the name diluting segment. Na+ entry down an electrochemical gradient drives the uphill transport of K+ and Cl. This system depends on the simultaneous presence of these three ions in the luminal fluid. Once inside the cell, K+ passively reenters the lumen (K+ recycling) via conductive K+ channels in the apical membrane. Cl, on the other hand, exits the cell via conductive Cl channels in the basolateral membrane. Depolarization of the basolateral membrane occurs as a consequence of Cl efflux, creating a lumen-positive (relative to the interstitial fluid) transcellular potential difference of approximately 10 mV. This drives paracellular cation transport, including Na+, Ca++, and Mg++. Inhibition of the NKCC2 cotransporter not only results in excretion of Na+ and Cl but also in excretion of divalent cations, such as Ca++ and Mg++.



Based on its molecular structure, the NKCC2 cotransporter belongs to a family referred to as electroneutral Na+/Cl cotransporters, which also includes the Na+/Cl cotransporter (NCC) sensitive to thiazide diuretics. These proteins have a structure similar to NHE3 and appear to be up regulated by reduction of intracellular Cl activity and cell shrinkage. Bartter’s syndrome (a renal tubular disorder) type I kindreds apparently have mutations in the gene encoding the NKCC2 transporter; Types II and III of this syndrome result from mutations in channels. The well-recognized countercurrent mechanism in the renal medulla depends on the activity of this cotransport system, and drugs that inhibit this pathway diminish the ability of the kidney to excrete urine that is either more concentrated or more dilute than plasma.


In summary, fluid is reabsorbed from the lumen of the descending limb of the loop as it progresses deeper into the medullary areas of higher osmotic pressure. Electrolyte concentrations increase to a maximum at the bend and gradually decrease as the NKCC2 cotransport mechanism and Na+ pump, working in tandem, achieve reabsorption of Na+, K+, and Cl. The thick ascending limb reabsorbs 25% of filtered NaCl and 40% of filtered K+, but not water, whereas the entire loop reabsorbs 15% of the fluid.



Tubular Reabsorption: Transport by the Distal Convoluted Tubule


In contrast to the proximal tubule and loop of Henle, there is less reabsorption of water and electrolytes in the distal convoluted tubule. It reabsorbs approximately 10% of the filtered load of NaCl. Similar to the thick ascending limb, this segment is impermeable to water, and the continuous reabsorption of NaCl further dilutes tubular fluid. NaCl entry across the apical membrane is mediated by the electroneutral NCC cotransporter sensitive to thiazide diuretics (Fig. 21-5). Unlike the NKCC2 cotransporter of the thick ascending limb, this cotransporter does not require participation of K+. As in other segments, the basolateral Na+/K+-ATPase provides the low intracellular Na+ concentration that facilitates downhill transport of Na+. The distal tubule does not have a pathway for K+ recycling, and therefore the transepithelial voltage is near zero. Therefore the reabsorption of Ca++ and Mg++ is not driven by electrochemical forces. Instead, Ca++ crosses the apical membrane via a Ca++ channel and exits the basolateral membrane via the NCC exchanger. Thus, by inhibiting the NCC cotransporter, thiazide diuretics indirectly affect Ca++ transport through changes in intracellular Na+. Another mechanism of increased Ca++ reabsorption with thiazide diuretics is an increase in the intracellular concentrations of Ca++-binding proteins.



Recently, inactivating mutations have been found in the human gene encoding the NCC transporter in patients with Gitelman’s syndrome, characterized by hypotension, hypokalemia, hypomagnesemia, and hypocalciuria, similar to the effects of thiazides. Pseudohypoaldosteronism type II is an autosomal dominant disease characterized by hypertension, hyperkalemia, and sensitivity to thiazide diuretics. It has been suggested that an activating mutation of the NCC cotransporter is responsible. Recently, two protein kinases have also been linked to the pathogenesis of this syndrome. They are found in the distal nephron and are thought to control the activity of the cotransporters.



Tubular Reabsorption: Transport by the Collecting Tubule


The collecting tubule is the final site of Na+ reabsorption, and approximately 3% of filtered Na+ is reabsorbed by this segment. Although the collecting tubule reabsorbs only a small percentage of the filtered load, two characteristics are important for diuretic action. First, this segment is the site of action of aldosterone, a hormone controlling Na+ reabsorption and K+ secretion (see Chapter 39). Second, virtually all K+ excreted results from its secretion by the collecting tubule. Thus the collecting tubule contributes to the hypokalemia induced by diuretics.


The collecting tubule is composed of two cell types with separate functions. Principal cells are responsible for the transport of Na+, K+, and water, whereas intercalated cells are primarily responsible for the secretion of H+ or image. Intercalated cells are of two types, A and B, the former responsible for secretion of H+ via an H+-ATPase (primary active ion pump) in the apical cell membrane, and the latter responsible for secretion of image via a Cl/image exchanger in the apical membrane. In contrast to more proximal cells, the apical membrane of principal cells does not express cotransport or countertransport systems; rather it expresses separate channels that permit selective conductive transport of Na+ and K+ (Fig. 21-6). Na+ is reabsorbed through a conductive Na+ channel. The low intracellular Na+ as a result of the basolateral Na+/K+-ATPase generates a favorable electrochemical gradient for Na+ entry through epithelial Na+ channels (ENaCs). Because Na+ channels are present only in the apical cell membrane of principal cells, Na+

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Jun 18, 2016 | Posted by in PHARMACY | Comments Off on Diuretic Drugs

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