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We can now quantify the kidneys contribution to hydrogen ion balance In other words, we can calculate the kidneys net bicarbonate addition to the body or elimination from it This value is, again, identical to the kidneys net excretion of hydrogen ions ( acid ) Such a calculation is made by answering 3 questions: 1 2 How much bicarbonate is excreted in the urine This represents bicarbonate loss from the body It is measured simply by multiplying the urine flow rate by the urinary bicarbonate concentration How much new bicarbonate is contributed to the plasma by secretion of hydrogen ions that combine in the tubular lumen with non-bicarbonate urinary buffers This can be measured by titrating the urine with NaOH to a pH of 74, the pH of the plasma from which the glomerular filtrate originated This simply reverses the events that occurred within the tubular lumen when the tubular fluid was titrated by secreted hydrogen ions Thus, the number of milliequivalents of sodium hydroxide required to raise the pH back to 74 must equal the number of milliequivalents of hydrogen ion added to the tubular fluid that combined with phosphate and organic buffers This value is known as the titratable acid How much new bicarbonate is returned to the plasma by secretion of hydrogen ions that are excreted as ammonium The titratable acid measurement will not titrate hydrogen ions in NH+ because ammonium is such a weak 4 acid with a pK of the ammonia-ammonium reaction so high (92) that titration with alkali to pH 74 will not remove hydrogen ions from NH4+

Leaders get paid for results, not for being right Results come from mistakes being wrong and leaders must possess Lombardi s mental toughness to handle mistakes, take accountability for them, and quickly abandon those efforts that fail to produce results

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3 The secretory processes in the medullary collecting ducts are highly complex Ammonia taken up from the medullary interstitium and secreted across the apical membrane involves both diffusive flux and transporter-mediated flux In both cases, the secreted ammonia is matched by a secreted proton to reform ammonium in the tubular lumen In the deepest portions of the medulla, there is probably a parallel route of ammonium transport in which ammonium is taken by the Na-K-ATPase, with ammonium substituting for potassium By reabsorbing ammonium in the medullary thick ascending limb, luminal ammonium in the cortical collecting duct does not become concentrated to the high level it would otherwise as a result of the major reabsorption of water In the inner medulla, however, the tubular concentration can be rather high, with secretion still favored because of the high interstitial ammonium concentration

W H AT I T TA K E S T O B E # 1

then use these benchmarks for designing your application Consider your user population and answer the question, what is a reasonable amount of time that they will wait for data to be delivered when they request it Use the benchmark data to determine the amount of data that you can send in this period of time and use this as the upward bound when designing the application Also realize that there is a lot of hype in the market in terms of network speed Faster networks are coming, but wireless is working well in many applications around the world today There is no need to wait for the promise of faster networks

If you are right all the time, you are not taking enough risks Results require a willingness to act, even if you are unsure of what lies ahead Only through action and risk can you take your company to the next level

regulation of hydrogen ion balanCe / 175

Boldness: We make way for the man who boldly pushes past us Who bravely dares must sometimes risk all

Alkalosis Titratable acid (mmol/day) plus NH excreted (mmol/day)

One of the issues mentioned previously in relation to speed and coverage is network capacity It is important to probe beneath the surface to determine the capacity of the network in your critical coverage areas and at what percentage of capacity the network is currently operating Also ask what capacity is being used during high points of the day when your users will need to send their data Network congestion has peaks and valleys, similar to highway congestion during rush hour By understanding the conditions of the network congestion, you can make a more informed network choice and, possibly, design your application to pass large amounts of information during times when the network isn t very congested

Results, specific and measurable, come from having a clear vision, defining what improvement and adaptation look like, and having a beginning and end in mind Results come from knowing what you are achieving today and having a clear, specific strategy for closing the gap between today s reality and your vision for tomorrow Perhaps you don t want to be a Lombardi type of leader, challenging, demanding, at times intimidating Maybe you don t believe you can be that kind of leader That s fine, as long as you can produce results with whatever style you prefer But keep in mind that ultimately, it s not whether your people like you or approve of you; it s whether they produce for you

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Obviously a key issue is network reliability If your mission-critical application is dependent upon getting data through, you need a very reliable system and network partner

The leader does not exist in the abstract, but rather in terms of what he does in a specific situation

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