Figure

Active renal elimination of an organic anion. The transport mechanism is in the peritubular portion of the membrane of the proximal tubular cell.

have its own characteristic maximum rate of secretion (transport maximum, Tm).

Some drugs that are not candidates for active tubular secretion may be metabolized to compounds that are. This is often true for metabolites that are formed as a result of conjugative reactions. Because the conjugates are generally not pharmacologically active, increases in their rate of elimination through active secretion usually have little effect on the drug's overall duration of action.

These active secretory systems are important in drug excretion because charged anions and cations are often strongly bound to plasma proteins and therefore are not readily available for excretion by filtration. However, since the protein binding is usually reversible, the active secretory systems can rapidly and efficiently remove many protein-bound drugs from the blood and transport them into tubular fluid.

Any drug known to be largely excreted by the kidney that has a body half-life of less than 2 hours is probably eliminated, at least in part, by tubular secretion. Some drugs can be secreted and have long half-lives, however, because of extensive passive reabsorption in distal segments of the nephron (see Passive Diffusion, earlier in the chapter). Several pharmacologically active drugs, both anions and cations, known to be secreted are listed in Table 4.5.

It is important to appreciate that these tubular transport mechanisms are not as well developed in the neonate as in the adult. In addition, their functional capacity may be diminished in the elderly. Thus, compounds normally eliminated by tubular secretion will be excreted more slowly in the very young and in the older adult. This age dependence of the rate of renal drug secretion may have important therapeutic implications and must be considered by the physician who prescribes drugs for these age groups.

Finally, compounds that undergo active tubular secretion also are filtered at the glomerulus (assuming protein binding is minimal). Hence, a reduction in secretory activity does not reduce the excretory process to zero but rather to a level that approximates the glomerular filtration rate.

Active Tubular Reabsorption

Some substances filtered at the glomerulus are reabsorbed by active transport systems found primarily in the proximal tubules. Active reabsorption is particularly important for endogenous substances, such as ions, glucose, and amino acids (Fig. 4.4), although a small number of drugs also may be actively reabsorbed. The probable location of the active transport system is on the luminal side of the proximal cell membrane. Bidirectional active transport across the proximal tubule also occurs for some compounds; that is, a drug may be both actively reabsorbed and secreted. The occurrence of such bidirectional active transport mechanisms across the proximal tubule has been described for several organic anions, including the naturally occurring uric acid (see Chapter 37). The major portion of filtered urate is probably reabsorbed, whereas that eventually found in the urine is mostly derived from active tubular secretion.

Most drugs act by reducing active transport rather than by enhancing it. Thus, drugs that promote uric acid loss (uricosuric agents, such as probenecid and sulfin-pyrazone) probably inhibit active urate reabsorption, while pyrazinamide, which reduces urate excretion, may block the active tubular secretion of uric acid. A complicating observation is that a drug may primarily inhibit active reabsorption at one dose and active secretion at another, frequently lower, dose. For example, small amounts of salicylate will decrease total urate ex-

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