This is the updated (2017-18) version of this lecture series, and it contains some additional and fairly recent information.

1. Drugs Acting on the Kidney (1 and 2)
Professor John Peters
E-mail j.a.peters@dundee.ac.uk

2. Learning Objectives
Following this lecture, students should be able to:
 Recall the range of drugs that act upon the kidney
 Identify the major sites of diuretic action in the nephron
 Describe in detail the mechanism of action of the loop diuretics
 List the clinical uses and main adverse effects of the loop diuretics
 Describe in detail the mechanism of action of the thiazide diuretics
 List the clinical uses and main adverse effects of the thiazide
diuretics
 Explain why loop and thiazide diuretics cause hypokalaemia
 Describe the mechanisms of action of the potassium sparing
diuretics noting the distinct modes of action of aldosterone
antagonists and blockers of the epithelial sodium channel, ENaC
 Describe the clinical uses of the potassium sparing diuretics and
their adverse effects
 Recommended reading
• Neal (2016). ‘Medical Pharmacology at a Glance (8th.ed.) Chapter 14
• Rang, Ritter, Flower and Henderson (2016). 'Rang and Dale's
Pharmacology’ (8th. ed.). Chapter 29.

3. Drugs Acting on the Kidney
Drugs acting on the kidney include
Diuretics are the most commonly used agents that:
 increase urine flow, normally by inhibiting the reabsorption of
electrolytes (mainly sodium salts) at various sites in the nephron
 Diuretics
 Vasopressin (antidiuretic hormone; ADH) receptor agonists and
antagonists
 Uricosuric drugs (agents promoting excretion of uric acid into the
urine)
 are used to enhance excretion of salt and water in conditions where
an increase in the volume of interstitial fluid (i.e. oedema) causes
tissue swelling
 Inhibitors of sodium-glucose co-transporter 2 (SGLT2)
 Those used in renal failure
 Those that alter the pH of the urine

4.  Formation of interstitial fluid is proportional to: (Pc – Pi) – (p - i)
 Disease states that increase Pc or decrease p and produce
oedema include:
• the nephrotic syndrome
Oedema
 results from an imbalance between the rate of formation and
absorption of interstitial fluid
Pc p
Pi i
Capillary
Interstitial fluid
• hepatic cirrhosis with ascites
• congestive heart failure

5. Diseases Associated With Oedema Responding to
Diuretic Drug Therapy
The Nephrotic Syndrome
 Involves a disorder of glomerular filtration, allowing protein
(largely albumin) to appear in the filtrate (proteinuria)
Decreased p
formation of
interstitial fluid
blood volume
 cardiac output
Oedema
Activation of the
RAAS
Na+ and H20
retention
Pc, p

6. Congestive Heart Failure
 Arises from reduced cardiac
output. Subsequent renal
hypoperfusion activates the renin-
angiotensin system
 Expansion of blood volume
contributes to increased venous
and capillary pressures which,
combined with reduced p, causes
pulmonary and peripheral oedema
Hepatic Cirrhosis With Ascites
 Increased pressure in the hepatic
portal vein, combined with decreased
production of albumin, causes loss of
fluid into the peritoneal cavity and
oedema (ascites)
 Activation of the renin-angiotensin
system occurs in response to
decreased circulating volume
Oedema fluid mobilization by
diuretics. Note that collapse and
danger of thrombosis only occur
if massive use of diuretics is
employed). From Lüllmann et al.
(2000) Color Atlas of
Pharmacology

7. Sodium Reabsorption and the Major Sites of
Diuretic Action in the Nephron
Proximal convoluted tubule
1. Na+ (passive Cl- absorption)
2. Na+/H+ exchange (blocked by
carbonic anhydrase inhibitors)
Thick ascending limb of the loop of Henle
3. Na+/K+/2Cl- co-transport (blocked
by loop diuretics)
Distal convoluted tubule
4. Na+/H+ exchange (blocked by
carbonic anhydrase inhibitors)
5. Na+/Cl- co-transport (blocked by
thiazide diuretics)
Collecting tubule
6. Na+/K+ exchange (blocked by
potassium-sparing diuretics)
1
2
3
4
5
6

8. Diuretics – General Aspects
 A very large proportion of NaCl and H2O that passes into the filtrate
via the glomerulus is reabsorbed – hence even a small inhibition of
reuptake can cause a marked increase in Na+ excretion
 The site of action of many diuretics (thiazides, loop agents, potassium
sparing) is the apical membrane of tubular cells hence, if hydrophilic,
they must enter the filtrate to access that site
 Entry to the filtrate is by either:
o glomerular filtration (for drug not bound to plasma protein)
o secretion via transport process in the proximal tubule
o two transport systems are important
• the organic anion transporters (OATs) – transport acidic drugs (e.g.
thiazides and loop agents)
• the organic cation transporters (OCTs) – transport basic drugs (e.g.
triamterene and amiloride)
o secretion results in the concentration of diuretic in the filtrate being higher
than that in blood, contributing to pharmacological selectivity

9. Secretion of Diuretics in the Proximal Tubule
 Organic anion transporters (OATs)
o At the basolateral membrane organic
anions (OA-) enter cell by either diffusion,
or in exchange for α-ketoglutarate (α-KG)
via OATs
o α-KG is transported into cell (against a
concentration gradient) via a Na+-
dicarboxylate transporter
o At the apical membrane, OA- enters the
lumen via either multidrug resistance
protein 2 (MRP2), or OAT4 (in exchange for
α-KG)
 Organic cation transporters (OCTs)
o At the basolateral membrane organic cations
(OC+) enter the cell either by diffusion, or
OCT, (both driven by negative potential of
cell interior and against a concentration
gradient)
o At the apical membrane, OC+ enters the
lumen via either multidrug resistance protein
1 (MRP1), or OC+/H+ antiporters (OCTN)

10. Mechanism of Action of Loop Diuretics
Na+
Na+
Na+
K+K+
K+ K+
Cl-2Cl- Cl-
Zona occludens
+ve -ve4-10 mV
Lumen Interstitium
Mg2+
Ca2+
Mg2+
Ca2+
Loop
diuretics
block
Maintainhightonicity
ofthemedulla
Tubular epithelium
of the TAL
Triple transporter
(Na+/K+/2Cl- co-
transporter; NKCC2)
K+/Cl- co-transporter
Na+/K+ ATPase
Key
K channel (ROMK)
Cl channel
TAL = thick
ascending limb of
the loop of Henlé

11. Pharmacodynamics
 Inhibit the Na+/K+/2Cl- carrier by binding to the Cl- site and thus:
Loop Diuretics (1)
Principal drugs: Furosemide and Bumetanide
 Possess an additional, indirect, venodilator action (before diuresis)
that is beneficial in pulmonary oedema cause by heart failure–
possibly results from: 1) increased formation of vasodilating
prostaglandins; 2) decreased responsiveness to angiotensin II and
noradrenaline; 3) opening of K+ channels in resistance vessels
o increase the load of Na+ delivered to distal regions of the nephron
(causing K+ loss)
o decrease the tonicity of the interstitium of the medulla
o prevent dilution of the filtrate in the thick ascending limb
o increase excretion of Ca2+ and Mg2+
 Are ‘high ceiling’ agents causing 15-25% of filtered load of Na+ to
be excreted – rapid onset following IV administration

12. Loop Diuretics (2)
To treat hypertension (in patients resistant to other diuretics or anti-
hypertensive drugs - usually in the presence of renal insufficiency)
To reduce acutely elevated calcium levels in the serum
(hypercalcaemia) - note paracellular pathway in the thick
ascending limb of the loop of Henle
To increase urine volume in acute kidney failure
Clinical indications
To reduce salt and water overload associated with:
Acute pulmonary oedema (IV) Chronic heart failure
Chronic kidney failure Nephrotic syndrome
Hepatic cirrhosis with ascites
Pharmacokinetics
Well absorbed from the G.I. tract
Strongly bound to plasma protein
Enter nephron by the organic anion transport mechanism

13. Loop Diuretics (3)
 Potassium loss producing low serum potassium levels
(hypokalaemia) – corrected by the concomitant use of potassium
sparing diuretics or potassium supplements
(note increases toxicity of digoxin and Class III antidysrhythmic drugs)
 Increased plasma uric acid (hyperuricaemia) – partially
explained by competition between uric acid and loop agents
for the organic acid secretory mechanism in the proximal
tubule
 Depletion of calcium and magnesium (paracellular pathway)
 Decreased volume of circulating fluid (hypovolaemia) and
hypotension (particularly in the elderly)
 Shift in acid-base towards alkaline side (metabolic alkalosis) –
caused by increased H+ secretion from intercalated cells in
collecting tubule
Adverse effects

14. Mechanism of Action of Thiazide Diuretics
Na+
Na+
Na+
+
K+
K+
Cl-
Cl- Cl-
Zona occludens
Lumen Interstitium
Thiazide
diuretics
block
Tubular epithelium
of the early distal
tubule
Na+/Cl- co-transporter
K+/Cl- co-transporter
Na+/K+ ATPase
Key
Cl- channel
K+ channel
K+
K+

15. Pharmacodynamics
 Inhibit the Na+/Cl- carrier by binding to the Cl- site and thus:
 Cause up to 5% of Na+ to be excreted, producing a modest
diuresis
 Possess an additional, indirect, vasodilator action (mechanism
uncertain) that contributes to their effectiveness in the treatment
of hypertension (where they are used in combination with other
antihypertensive agents)
Thiazide Diuretics and Thiazide-Like (1)
Principal drugs: Bendroflumethiazide (thiazide): indapamide
and chlortalidone (thiazide-like)
o prevent the dilution of filtrate in the early distal tubule
o increase the load of Na+ delivered to the collecting tubule (causing
K+ loss)
o increase reabsorption of Ca2+ (cf. loop agents) (mechanism debatable)

16. Thiazide Diuretics (2)
 Nephrogenic diabetes insipidus [caused by diminished
vasopressin responsiveness of the collecting ducts (paradoxically,
thiazides decrease the volume of urine – mechanism poorly
understood]
 Renal stone disease (nephrolithiasis). Reduced urinary excretion
of Ca2+ discourages Ca2+ stone formation (mainly aggregates of
particles of calcium oxalate)
 Severe resistant oedema (with a loop agent)
…and additionally in:
Clinical indications
Widely used in:
 Mild heart failure  Hypertension
Pharmacokinetics
 Well absorbed from the G.I. tract
 Enter nephron by the organic anion transport mechanism
(proximal tubule)

17. Thiazide Diuretics (3)
Adverse effects
 Male sexual dysfunction
 Hyperuricaemia – mechanism as for loop agents – may
precipitate gout
 Metabolic alkalosis
 Depletion of magnesium (not calcium)
 Hypovolaemia and hypotension (particularly in the elderly)
 Hypokalaemia, particularly likely and corrected as for loop
diuretics
 Impaired glucose tolerance

18. Mechanism by which Loop and Thiazide Diuretics
Cause Potassium Loss – Relevant Physiology
Aldosterone, a steroid hormone,
acts via cytoplasmic receptors to:
1. increase synthesis of the
Na+/K+ATPase
2. increase synthesis of a protein
that activates the epithelial Na+
channel (ENaC)
increase the number of H2O channels
(aquaporins) in the cell membrane
ADH (vasopressin), a peptide
hormone, acts via G-protein
coupled receptors to:
Na+
Na+
K+
K+
Zona occludens
Lumen Interstitium
Late distal and collecting tubule
H2O
Cl-
Cl-
H2O
Na+
K+
K+ Channels (ROMK), secrete K+
into the urine in the collecting
tubule
Note that K+ effectively exchanges
for reabsorbed Na+

19. Mechanism by which Loop and Thiazide Diuretics
Cause Potassium Loss
Na+
Na+
K+
K+
Zona occludens
Lumen Interstitium
Late distal and collecting tubule
H2O
Cl-
Cl-
H2O
Na+
K+
1. Increased Na+ load caused by loop
or thiazide diuretic produces
enhanced reabsorption of Na+

2. Resulting charge separation
makes lumen more negative
and depolarizes the lumenal
vs. basolateral membrane
-ve
3. Increased driving force on K+
across the lumenal membrane
leads to enhanced secretion of
K+. (Secretion of H+ is similarly
affected)

4. Secreted K+ (and H+) ‘washed
away’ by increased urinary
flow rate – development of
hypokalaemia (and metabolic
alkalosis)

20. Mechanism of Action of the Potassium Sparing
Diuretics
Spironolactone and
Eplerenone
Compete with aldosterone for binding
to intracellular receptors causing:
1. decreased gene expression and
reduced synthesis of a protein
mediator that activates Na+
channels in the apical membrane
(site 1)
2. decreased numbers of
Na+/K+ATPase pumps in the
basolateral membrane (site 2)
Amiloride and Triamterene
Block the apical sodium channel
decrease Na reabsorption
Na+
Na+
K+
K+
Zona occludens
Lumen Interstitium
Late distal and collecting tubule
H2O
Cl-
Cl-
H2O
Na+
K+
X site 1
site 2

21. Potassium Sparing Diuretics
Spironolactone and eplerenone
Have limited diuretic action (modulated by aldosterone levels)
Competitively antagonise the action of aldosterone at cytoplasmic
aldosterone receptors, gain access to cytoplasm via the basolateral
membrane
Increase and decrease the excretion of Na+ and K+ respectively
Are well absorbed from the G.I. tract and in the case of spironolactone
rapidly metabolised to canrenone (which accounts for most of the
action of the drug)
Amiloride and Triamterene
Block lumenal sodium channels in the collecting tubules. Effect on ion
fluxes are similar to those of spironolactone
Enter the nephron via the organic cation transport system in the
proximal tubule
Triamterene is well absorbed from the G.I tract, absorption of amiloride
is poor

22. Clinical indications
 The major use of potassium sparing diuretics is in conjunction
with other agents that cause potassium loss. Given alone, they
cause hyperkalaemia
 Aldosterone antagonists are used in the treatment of:
o heart failure
o primary hyperaldosteronism (Conn’s syndrome)
o resistant essential hypertension
o secondary hyperaldosteronism (due to hepatic cirrhosis with
ascites)
 Thiazide and loop diuretics activate the renin-angiotensin-
aldosterone system (in response to reduced blood pressure)
Aldosterone antagonists potentiate the actions of thiazide and
loop agents by blocking the effect of aldosterone