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Articles in PresS, published online ahead of print August 6, 2002
Am J Physiol Renal Physiol, 10.1152/ajprenal.00164.2002
Submitted on April 29, 2002
Accepted on July 25, 2002
1 Department of Physiology and Biophysics, Weill Medical College of Cornell University, New York, NY, USA
* To whom correspondence should be addressed. E-mail: alan{at}nephron.med.cornell.edu.
The present clinical taxonomy of distal renal tubular acidoses includes "gradient", "secretory", and "voltage" defects. These categories refer to presumed collecting duct defects in which the epithelium may be abnormally permeable and unable to sustain an ion gradient, in which luminal proton ATPases are defective, or in which electrogenic Na+ reabsorption is impaired and luminal electronegativity is reduced. Classification of affected individuals is based on urine pH and ion concentrations during spontaneous acidosis and during SO=4 infusion, as well as urine pCO2 during HCO-3 loading. A model of rat CD has been developed which has been used to examine determinants of urine acidification (Weinstein, 2002a), and the interplay of HCO-3 and PO4 loads to generate a disequilibrium pH and equilibrium pCO2 (Weinstein, 2002b). In this paper, pure forms of gradient, voltage, and secretory defects are simulated, with attention to variability in the locus of the defect in cortical (CCD), outer medullary (OMCD), or inner medullary collecting duct (IMCD). The objective of these calculations is to discover whether the intuitive description of these defects is sustained quantitatively. The most important positive finding is that the locus of the transport defect along the CD plays a critical role in the apparent severity of the lesion, with more proximal defects being less severe and more easily correctable. In particular, model calculations suggest that for gradient or secretory defects to be clinically detectable they need to involve OMCD and/or IMCD. Additionally, the calculations reveal a possible mechanism for CD K+ wasting, which does not involve failure of H,K-ATPase, but which derives from a paracellular anion leak and thereby a more electronegative lumen. The most important negative finding is the lack of support for the category of renal tubular acidosis associated with a voltage defect. Although CD lesions that present with both K+ and H+ secretory defects suggest mediation by transepithelial electrical PD, both the PD changes and proton pump PD sensitivity appear too small to account for the observed abnormalities.
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