The mechanisms of renal tubular dysfunction in old age have been examined in twenty-eight clinically healthy elderly subjects without infection, and in fourteen subjects of similar age with laboratory evidence of intrarenal infection. The data were compared with those from thirteen clinically healthy young subjects. Studied were: proximal tubular (Tm(PAH)) and distal tubular (CH2O) activity, minimal and maximal osmolal U/P ratios, maximal osmolal excretion in hydropenia, and GFR levels under standard hydration and under water-loading. The reduction of GFR in old age is evident particularly in men under conditions of standard hydration: it is accentuated in the presence of renal infection. Proximal tubular activity is also significantly lower in elderly men, especially if they have chronic bacteriuria. The reduction is closely related to GFR levels, with identical Tm(PAH):C(in) ratios in all groups. This supports the intact nephron hypothesis for this part of the nephron. Distal tubular activity is depressed in old age in both sexes proportionately more than proximal tubular activity or the GFR. The lower CH2O: GFR ratios imply a selective distal tubular damage. Maximal osmolal U/P ratios in hydropenia are significantly higher in the young (mean 367) than in either the elderly non-infected (mean 279) or the elderly infected subjects (mean 212). Conversely, minimal U/P ratios in water-loading are lower in the young (mean 0.247) than in either elderly group (means 0.418 and 0.668). Osmolal excretion in hydropenia is not different between the groups, but urine flows in water-loading clearly separate them. The data indicate that simple functions of the distal-collecting tubule (e.g. the CH2O), are less affected in old age than are functions involving several medullary structures (as is the maximal U(osm) or U/P ratio). They suggest that the main impairment of the distal tubular cell involves the failure to achieve a proper osmotic gradient between tubular fluid and blood, rather than an inability to excrete or re-absorb an adequate amount of solute. Finally, it appears that renal infection aggravates the larger glomerular and proximal tubular deficits observed in non-infected men: it depresses distal tubular function equally in both sexes.
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