All of the following substances are added to the urine by means of tubular secretion, except
**Core Concept**
Tubular secretion is a process by which the kidneys eliminate waste products and excess substances from the blood by secreting them into the urine. This process involves the transport of substances from the peritubular capillaries into the renal tubular lumen.
**Why the Correct Answer is Right**
The correct answer involves identifying a substance that is not secreted by the renal tubules. The kidneys use both filtration and secretion to remove waste products from the blood. Substances like para-amino hippurate (PAH), which is a marker of renal plasma flow, are secreted by the proximal tubular cells into the lumen. However, not all substances are secreted in this manner.
**Why Each Wrong Option is Incorrect**
**Option A:** **Para-amino hippurate (PAH)** is secreted by the proximal tubular cells into the lumen, making it a correct example of tubular secretion.
**Option B:** **Urea** is primarily reabsorbed in the proximal convoluted tubule, but a small amount is secreted by the collecting ducts, making it not a pure example of tubular secretion but still related.
**Option C:** **Calcium** is primarily reabsorbed in the proximal and distal convoluted tubules, but in some conditions, it can be secreted by the collecting ducts, so it's not the best example of a substance not secreted by the kidneys.
**Option D:** **Creatinine** is primarily filtered by the glomerulus and reabsorbed in the proximal convoluted tubule, with minimal secretion by the renal tubules.
**Clinical Pearl / High-Yield Fact**
The kidneys have a remarkable ability to adjust the amount of substance secreted based on the body's needs. For example, during exercise, the kidneys increase the secretion of PAH to increase renal plasma flow and help eliminate excess lactic acid.
**Correct Answer: D. Creatinine**