Disorders of The Urinary system

General introduction
Jining medical college
affiliated hospital
qiubo
Tel:15153701881
Main contents
anatomic structure of the kidneys
physiological function
approach of renal diseases
clinical syndromes
treatment of renal diseases
Anatomic Structure of The kidney
•Retroperitoneally on
the posterior of the
abdomen
•11cm long 6cm wide
4cm thick
nephron
Bowman,s capsule
Renal corpuscle
glomerulus

nephron
Proximal tubule

Loop of henle
Renal tubule
Distal tubule
Collecting duct
 URINARY SYSTEM

1,000,000nephro
ns in each
kidney

Formed by the invagination

of a tuft of capillaries into
the blind end of a nephron
Cortical nephron
In the outer part of the cortex, have
Corresponding short loop of henle
Juxtamedullary nephron
In the inner part of the cortex,
With long loop of henle
 Structure of The membrance

•Be made up of three layers

•Is a continuous layer of
connective tissue and
glycoprotein
•The epicilial cells is also called
podocytes

Figure 3.
Fig. Glomerular basement membrane (GBM)
 URINARY SYSTEM

•Epithelial cells are also

called podocytes which
has large extensions or
trabeculae project out
from the cell body and
embedded in the
basement membrane
surrounding a capillary
•There are slit pores
between the adjacent
trabecular, which
control the movement
of substances through
the final layer of the
filter
 PODOCY
TE

1°
proces
s

pedicels
2
°
 URINARY SYSTEM

Mesangium sonsists of
mesangial cell and martrix
which provide structure
support for the capillary
Exhibit phagocytic activity
Secrete extraceliular matrix
and prostaglandins
May contribute to regulation
of blood flow through the
glomerular capillaries
GFR  Renin
Angiotensin
Blood Pressure

JGA
Major Functions of The Kidney
• Regulation of osmolality of the body fluid
• Regulating the volume of the extracellular fluid
• Regulating concentrations of electrolytes of the
extracellular fluid
• Regulation of acid-base balance
• Clearance of metabolic waste products (urea, uric
acid, creatinine)
• Production of special substances (erythropoietin,
renin, prostaglandins, and thromboxane)
Physiological functions
 Ultrafiltrate form
favoring forces:hydraulic pressure in
the glomerular capillaries
opposing forces:hydraulic pressure
in bowman space,colloid osmotic
pressure in the capillaries
Net Filtration Pressure

BHP 60 out
10 out
COP 32 in
NFP
CP 18 in

Blood hydrostatic pressure(BHP) 60 mmHg out

Colloid osmotic pressure(COP) -32 mmHg in
Capsular pressure(CP) -18 mmHg in
Net filtration pressure(NFP) 10 mmHg out
Physiological functions
 Reasons for decreasing of GFR
1;glomerular hydraulic pressure
2;tubule hydraulic pressure
3;plasma colloid osmotic pressure
4;renal blood flow is reduced
5;permeability is reduced
6;filtration surface is diminished
Tubular reabsorption and secretion
 180L ultrafiltration of plasma in adults,but only 1-1.5L
final urine be produced, which occupy 1%
 Proximal tubule: reabsorb 70% of the Na+,80% of the
water, and all of glucose and amino acids
 Loop of henle:reabsorb 20% of the Na+, 10% of the
water,and produce a hypertonic interstitial fluid in the
medulla
 Distal tubule: reabsorb of the Na+ is coupled with
reabsorption of Ca 2+ ,Mg 2+ ,and secretion of K+and H+
 Collecting duct: regulation of the concentration and
volume of final urine
Renal endocrine
 Rennin
vasoavtive
 Angiotensin Regulate renal hemodynamic change
 Prostaglandin Control the balance of water and salt
 Kinin
 Erythropoietin nonvasoactive
Act on the general body
 1αhydroxylase
Approach to renal disease
 Present with renal disease in two ways:
discovered incidentally, or with evidence of renal
dysfunction such as hypertension, nausea,
edema,hematuria
 Estimation of disease duration
 A carefully urinalysis
 An assessment of the GFR
 Further diagnostic categorization according to Anatomic
prerenal disease glomerular
postrenal disease tubular
intrinsic renal disease interstitial
vascular abnormalities
Approach to renal disease
disease duration Over hours to days
 acute renal failure Retention of nitrogenous wasts
and creatitine
called azotemia

 chron renal failure: over months to years

 Differentiation the two is important for diagnosis
treatment, and outcome
anemia oliguria small kidney
Diagnostic Tests—Urinalysis
 Constituents, characteristics of urine vary w/
dietary intake, drugs, care of specimen
 Normally clear, straw-colored; pH 4.5-8.0
 Appearance
 Cloudy
 Presence of l g protein, blood cells, bacteria, pus
 Dark color
 Hematuria (blood), excessive bilirubin, high concentration of
urine
 Unpleasant, unusual odor
 infection
Diagnostic Tests—Urinalysis
 Abnormal constituents (high in numbers)
 Blood (hematuria)
 Small, microscopic amts
 Infection, inflammation, tumors of UT
 Lg # RBC
 Increased glomerular permeability or hemorrhage in tract
 Protein (Proteinuria)
 Leakage of albumin into filtrate
 Inflammation, increased glomerular permeability
 Bacteria (Bacteriuria) and Pus (Pyuria)
 Indicates UTI
 Urinary casts
 Microscopic mold of tubules
 Consists of one or more cells, bacteria, protein
 Inflammation of tubules
 Specific gravity
 Ability of tubules to concentrate urine
 Low is related to renal failure
RBC Cast
Proteinuria
 >150mg/24h
 Reasons

1. functional proteinria: to be benign process stem from acute illness,

exercise, and orthostatic proteinuria
a.usually under 30 years old
b.typically less than 1.0g/d
c.8-hour overnight supine urinary proteins excretion less < 50mg
2. over-load proteinuria:
a.result from overproduction of circulating filterable plasma
proteins such as Bence-jones proteins
b.urinary protein elctrophoresis will exhibit a discrete protein peak
c. other examples of overload ptoteinuria include myoglobinuria in
rhabdomyolysis,and hemoglobinuria in hemolysis
Proteinuria
3. Glomerular proteinuria: from injury of glomerular filtration barrier and
altered glomerular permeability across damaged GBM
4. Tubular proteinuria:
a.occurs as a result of faulty reabsorption of normal filtrated proteins
in the poximal tubule, such as microglobulin and immunoglobulin.
b.cause include acute tubular necrosis, toxic injury, drug induced
interstitial nephritis, and hereditary metabolic disorder
5. 24h urine collection:>3.5g/d is consistent with nephrotic-range
proteinuria,but is not easy to execute
The ratio of Urinary protein to Urinary creatinine is correlated with
24-hour urine collection
hematuria

cystitis
 Extraglomerular calculi
interstitial nephritis
(90%)
renal neoplasm

IgA nephropathy
thin GBM disease
 glomerular causes postinfectious glomerulonephritis
(10%) membranoproliferative
glomerulonephritis
systemic nephritic syndrome
Estimation of GFR
 Glomerular filtration rate (GFR)
 Provides a useful index of overall renal function,
measures the amount of plasma ultrafiltered
across the glomerular capillaries and correlates
with the ability of kidneys to filter fluids and
various substances
 Can be measured by determining the renal
clearance of plasma substance that are not
bound to plasma proteins, and are freely filtrate
across the glomerulus, and are neither secreted
nor reabsorbed along the renal tubules
Estimation of GFR
 Normal 100-120ml/min
 Means : inulin creatinine
 MDRD formula
GFR =186 x Scr -1.154 x Age -0.203
 Cockroft-Gault

(140 - Age) x Weight(Kg)

Ccr(ml/min)=
Scrx72
 The ratio of BUN / creatinine 10:1
Imaging studies
 Radionuclide studies
technetium-labeled
 Provide an assessment of functional renal
mass, and plasma flow, and to determine
the contribution of each kidney to overral
renal function, to detect obstruction, and
to evaluate renovascular disease
 Imaging studies
ultrasonography
Identify the thickness and
echogenicity of the renal cortex,
medulla, and pyramids, and
urinary collecting system
 Intravenous urography
Intravenous pyelogram (IVP)
Provide an assessment of the kidneys
ureters, and bladder.
Assess renal size and shape
Detect and localize renal stones
Assess renal function
Particularly useful in diagnosing
medullary sponge kidney and
papillary necrosis
 Computed tomography
CT
Especially useful for evaluation of
solid and cystic lesions in the
kidney or retroperitoneal space,
particularly if the ultrasound
results are suboptimal
 Magnetic resonance imaging
MRI
•For some solid lesions MRI may
be superior to CT
•Contrast is contraindicated, MRI
can be choose
•Adrenals are well imaged
•Specific for the diagnosis of
renal artery stenosis
 Arteriography and venography

•Arteriography is useful in
evaluation atherosclerotic or
fibrodysplatic stenotic lesions
•Venography is the best test for
diagnosis of renal vein thrombosis
Renal biopsy
Is important to identify the cause, guide
treatment, and to estimate prognosis
Indications
Acute renal faiture or chronic renal insufficiency
Acute nephritic syndromes
Proteinuria or hematuria
Systemic diseases associated with kidney dysfunction
Transplant rejection
Renal biopsy
Relative contraindication
Solitary or ectopic kidney
Uncorrected bleeding disorder (uncontrolled bleeding)
Severe uncontrolled hypertension (bleeding)
Renal infection (bacteremia,blood poisoning)
Renal neoplasm
Hydronephrosis ESRD
Congenital anomalies Multiple cysts
Uncooperative patient Horseshoe kidney
Normal Kidney:
Renal biopsy

Focal segmental glomerular sclerosing nephritis

Renal biopsy

Mesangial proliferative glomerulonephritis

 Renal biopsy

Immunofluorescence
microscope
Crescentic
glomerulonephritis
There are a lot of fibrin
deposit in the capsule
Clinical syndrome of renal disease
 Acute renal failure syndrome
 Acute rapidly progressive
glomerulonephritis syndrome
 Acute glomerulonephritis syndrome
 Chronic renal failure syndrome
 Nephrotic syndrome
 Asymptomatic urinary abnormalities
Nephritic Nephrotic
 Hematuria  Proteinuria
 Proteinuria (“nephrotic range”
 Hypoalbuminemia >3.5g/24h)
 Hypoalbumimenia
 Oliguria (GFR↓, Cr
↑, BUN↑)  Edema
 Edema (salt and  Hyperlipidemia
water retention)  Lipiduria
 Hypertension
Acute renal failure syndrome
 Rapid severe decrease in GFR, usually with reduced
urine output
 Extracellular fluid expansion leads to edema
hypertension, and occasionally to chronic renal failure
 Hyperkalemia, hyponatremia, and acidosis are common
ischemia
nephrotoxic injury
 Etiologies: renalvascular disease
pregnancy
prerenal or postrenal ailure
Acute rapidly progressive
glomerulonephritis syndrome
 Occurs over Weeks to months
 Oliguric or nonoliguric
 Hypertension is common
 Urinalysis:show hematuria, proteinuria,
and RBC casts
 Pulmonary manifestation range from
asymptomatic infiltrates to life-threating
hemoptysis
Chronic renal failure syndrome
 Progressive permanent loss of renal function over months to years,
and dose not cause symptom of uremia until GFR is reduced to
about 10-15ml/min
 Symptom
hypertension, anorexia, nausea, vomiting
insomnia, weight loss weakness
paresthesia, bleeding, serositis, anemia
acidosis, hyperkalemia
 Causes
diabetes mellitus hypertension
glomerular disease polycystic kidney disease
interstitial nephritis
Acute glomerulonephritis syndrome
 An acute illness with sudden onset of
hematuria, edema, hypertension,
oliguria,and elevated BUN and creatitine
 Pulmonary congestion
 RBC casts and serum complement may
be decreased
Nephrotic syndrome
 Albuminuria
 Edema
 Hypoalbuminemia
 Hyperlipidemia
 Complication
severe edema thrombosis events
infection protein malnutrition
Asymptomatic urinary abnormalities
 Hematuria with/or proteinuria without edema,
hypertension and renal function lesion
 causes
 Hematuria may be due to neoplasm, stone,
infection, sickle cell disease, IgA nephrotic or
analgesic abuse
 Modest proteinuria may be due to fever,
exertion, chronic heart failure, or upright posture.
renal causes include diabetes mellitus,
amyloidosis, or other glomerular diseases
Treatment of renal disease
 To slow the progression of CRD
 To prevent the extrarenal complicrtions
 Removal of predisposing factors
 Salt restriction and diuretics
 Immunosuppressive treatment
 Symptomatic treatment
 Renal replacement treatment
Treatment of renal disease
Immunosuppressive treatment
 Glucocorticoid and cyclophosphamide are
the mainstays of treatment
 Mycophemolate Mofeil (MMF) and
cyclosporin A (cycA) have been used in
some refractory glomerulonephritis, but
their long-term effects are still
controversial
Treatment of renal disease
Management of hypertension
 Two goals:

1.to slow the progression of chronic renal disease

2.to prevent the extrarenal complications of hypertension, such as
cardiovascular disease and stroke
 Be controlled to less than 130/80mmHg

in patients with diabetes or proteinuria >1.0g/24h,should be

controlled to 125/75mmHg
 Volume control with salt and restiction and diuretics is the mainstay
of therapy
 With the added consideration of cardioprotective benefit, ACEI and
ARB are commended firstly
Amelioration of proteinuria
 Proteinuria is now considered a risk
factor for both progressive nephron
injury as well as cardiovascular disease
 ACEI and ARB are effective in slowing
the progression of renal failure in
patients with diabetic and nondiabetic
renal failure, due to their proteinuria-
lowering effect
Renal replacement therapy
over the past 40years, renal replacement
therapy has prolonged the lives of many patients
with end stage renal disease
 Hemodialysis
 Continuous renal replacement therapies
 Peritoneal dialysis
 transplantation
Hemodialysis
 Heparin (anticoagulant)
 Required 3Xs/week for 3-4 hrs
 Is the most common therapeutic modality
for ESRD
Hemodialysis
Continuous renal replacement
therapy
 Severe acute renal failure
 Better tolerated hemodynamically
 Effective in removing fluid and simple to
perform
Peritoneal Dialysis
Peritoneal dialysis
 Administered in unit or at home
 At night or continuously
 CAPD (continuous ambulatory peritoneal dialysis)
 Peritoneal membrane serves as semipermeable membrane
 Dialyzing fluid instilled in catheter into cavity
 Allows exchange of wastes and electrolytes to occur
 Dialysate drained from by gravity from cavity into container
 Requires more time than hemo
 continuous exchange, prevents sudden changes in fluid and
electrolyte levels
 Complications
 Infection in peritoneal cavity
transplantation
 Most effective treatment
 Mycophanolate mofetil,cyclosporin,
leflunomide,and tacrolimus, the mortality
of the patients reduced
 Improved lifestyle and improved life
expectancy