the kidneys and urinary tract - ntnufolk.ntnu.no/audunfor/7....
TRANSCRIPT
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The Kidneys and Urinary Tract
Medicine for students in technology and science
MFEL 3010
Stein Hallan, MD PhD Dept. of Nephrology. St. Olav Universtiy Hospital
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Overview n 3 lectures covering
n Anatomy / physiology / diagnostic tools
n Diseases
n Dialysis
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2 kidneys""
2 ureteres""""
1 bladder""
1 uretra"
Urinary tract
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Tasks
n Kidneys n Remove waist products from the blood n Remove water n Produce hormons
n The rest n Transport the urine produced in the kidney
out of the body
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Anatomy
The kidneys and its nabour organs, seen form the front
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Anatomy
Position of the kidneys under the lower ribs and muscles, seen from behind
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Anatomy
Cross section showing the kidneys, spleen, stomach and liver (seen from above )
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Anatomy
Kidney with its capsule, artery, vein and ureter
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Anatomi
Cortex vs marrow, pyramides, collection system, fat.
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Anatomy
Arterial supply
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Anatomy
Urinary bladder, prostate, uretra
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Anatomy
2 nephrons: arteriole, glomerulus, tubulus, collecting ducts
Cortex Marrow Tip of pyramide
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Anatomy
Drawing of the Glomerulus
Blood
Urine
Capillaries (small blood vessels)
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Anatomy
Glomerulus Scanning Electron Microscope, 1000 x
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Anatomy
Glomerulus, vessels, tubulus Seen with a light- microscope, 400 x
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Anatomy
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Anatomy
The border beween the blood and the urinary space. Elektronmikroskop, 50000 x
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Physiology
Water reabs.
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Biochemical tests
n Autoanalyzers n Fully automatic n High throughput n Very precise results n Low price per test
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Biochemical tests for the kidney
n Blood (hematology) n Hemoglobin (Hb) n Leucocytes (white) n Trombocytes
(platelets) n Electrolytes
n Na n K n Ca n Phosphate
n Kidney function n Creatinine n Carbamide (urea)
n Other n Albumine n Bicarbonate
n Urine n Stix n Culture (bacterial)
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Biochemical tests n Hematology
n Flowcytometer n Single cells are examinded
with n Laser n Current / resistance n Staining
n 1000s of cells are characterised regarding
n Size n Nuclear size n Granularity n Enzyme content
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Biochemical tests
n Hematology n Microscopy
n Red blood cells n 2 different white
blood cells (leucoc.) n 1 platelet
(trombocyte)
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Imaging of renal disorders
n X-ray (± contrast medium) n Ultrasound n CT / MR n Angiography n Nuclear medicine
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Imaging
X-ray without contrast: Many big kidney stones
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Imaging
X-ray with iv contrast (urography): Normal
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Imaging
Ultrasound: Kidney with dilated renal pelvis due to obstruction Problems: low picture quality, time consuming, highly operator dependent.
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Imaging
Ultrasound: Kidney with 2 stones giving shaddows
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Imaging
Computer Tomography (cross sections through the kidneys, seen from below): Right: normal Left: reduced contrast enhancement, increased size, hematoma under the capsule after car crash Problems: High radiation dose, contrast toxicity
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Imaging
Angiography: Normal. Catether seen at top Problems: Expencive, high contrast dose, embolism (blood clots), radiation
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Imaging
Angiography: No kidney on right side, very narrow lumen (stenosis) in left artery. Dilated during the same procedure
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Imaging
CT Angiography: (non-invasive, computerbased reconsstruction of vessels and organs containing contrast)
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Common Diseases
n Urine infection n Prostate
n Benign enlargement n Cancer
n High blood pressure n Kidney stone n Chronic kidney failure
n Dialysis n Transplantation
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Urinary Tract Infection
n Bacteria n Gram neg. rods n E.Coli, Klebsiella,
Proteus, etc n Natural inhabitants
n Gut n Skin
n Defence mechanism n Flowing fluids n Mechanical barriers n Cells
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UTI - symptoms
n Lower n ”Cystitis” n No fever n Burning, pain, smell,
frequent voiding n Not dangerous
n Upper n ”Pyelonephritis” n Fever n Pain in back,
shivering, nausea, n Dangerous n Needs antibiotic,
sometimes hospitalization
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UTI- evaluation and treatment
n Urine n Dipstic (red and
white cells, bacteria) n Culturing
n Type n Effect of antibiotics
n Imaging n Obstruction n Reflux
n Antibiotics n Penicillins
n Ampicillin n Selexid
n Cefalosporins n Aminoglykocids n Trimetoprim, Sulfa
n Supportive treatment n IV fluids n BP-increasing drugs n Oxygen n etc
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Prostate - enlargement n Common
n Frequencey (%)= age
n Diffuse enlargement n Not cancer n Nodules (soft) n Increased outflow
resistance from bladder
n Symptoms n Frequent voiding n Nocturia n Difficult to start or stop n Sometimes without
symptoms
Normal 20 gr
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Prostate - enlargement
n Complikations n UT infections n Kidney failure
n Treatment n Bladder catheter
n Permanent n Intermitterent
n TURP n Other
n Local heating n Drugs Bladder: dilated and with
increased muscle trabecles
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Prostate - cancer
n Common n 20% of all men n Many dies with
and not due to the cancer
n Harde nodules
n Reasons n DNA damage n Testosteron-
dependent The tumor is composed of small glands that are lined by a single layer of hyperchromatic cells. In contract to normal glands, which have two layers, these neoplastic glands have only one layer and abut directly onto the interstitial connective tissue. A normal
prostatic duct appears at the far right.
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Prostate - cancer
n Symptoms n Local
n Obstruction n Blood in urine
(seldom)
n Metastases n Bone pain
n Treatment n Curative
n Prostate removal n Radiation of prostate
n Palliative n TURP n Castration (- testo)
n Surgical n Drugs
n Radiation of bone lesions
n X-ray n Radioactive
isotopes
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High blood pressure
140 cm water / blood column
10 cm (100 mm) Mercury (Hg)
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High blood pressure: frequency
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Hypertension: ”in the old days”
n US-president Roosevelt n 1938: 170/90, - sympt n 1941: 185/105 n 1943: 200/110, heart +
kidney failure n 1945: died of bleeding in
brain
n Treatment: n rest, saltrestriction,
sedativa
n Loss of years (untreated)
M 35 M 45 M 55
Normal 42 32 23
130/90 -4 -3 -1
140/95 -9 -6 -4
150/100 -16.5 -11.5 -6
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Hypertension: complications
….no critical border, but a continuum …
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Hypertension: lifestyle modificatons
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Hypertension: drug treatment
n Reduction of pressure n 8-15 mm Hg reduction
for most drugs
n Effect on clinical endpoints n 30-40% red. of stroke n 20% red. of heart
infarction
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Kidney stones
n Frequent disease n Causes
n Super-saturation of urine
n Calciumfosfat n Caliciumoxalat n Fosfat / infection n Urate
n Size n 1-80 mm. n < 6-7 mm will pass
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Kidney stones
n Symptoms n Very severe pain n Colic type, radiating
to groin n Blood in urine
n Examinations n X-ray
n Stone n Passage of urine
n Complications n Infection n Acute kidney failure n Chronic kidney
failure
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Kidney stones: treatment
n Fragmentation n Extracorporal shock
waves n Laser / US directly
on stone
n Removal n Laparascopy n Ureteroscopy
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Chronic kidney disease n Frequency
n Mild: 5% n Serious: 0.5% n Dialysis: 0.1%
n Progressive n Lifelong
n Causes n Kidney inflammation n Diabetes n High blood pressure n Atherosclerosis n Cystic diseases (genetic) n Infection / stone n Obstruction n other
n Cancer n Drugs n Inflammation in vessels
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Kidney failure (CKD stage 5) n Symptoms
n None at mild – moderate disease (stage 1,2,3 (4))
n Fatigue, lethargy n Nausea, vomiting n Anorexia, loss of muscle
mass n Itching
n Complications n Cardiovascular disease
n Heart infarction, angina n Stroke n Heart failure
n Anemia n Bone disease n Infections n Other
n bleeding n Nerve damage n Red fertility and sex
drive
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Kidney failure n Evaluation
n Blood tests n Hb n Na, K, Ca, Fosfat n Creatinine n Blood sugar, cholesterol
n Urine n Protein
n Ultrasound ex of kidney n Size n Obstruction n Scarring
Glomerular Filtration Rate (ml/min/1.73m2)
200150100500
s-C
reat
inin
e (m
ikro
mol
e/lit
re)
1000
800
600
400
200
0
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Kidney failure: treatment
n Mild - moderate n Reduce BP n Reduce u-protein n Strict blood sugar
control n Correction of
n Low hemoglobin (Epo)
n High phosphate n High potassium n Acid retention n Low calcium
n Serious n Dialyse n Transplantation
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Renal replacement therapy
Renal replacement therapy in NorwayStatus by end of year - pats. pr mill. inhabitants
0
20
40
60
80
100
120
140
160
180
82 84 86 88 90 92 94 96 98 100 102TL 05 /03
In dialysis
New in RRT
Tx performedWaiting list
00 02
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Dialysis
Hemodialysis Peritoneal dialysis
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n Semipermeable membrane
n Diffusion of small molecules
n Convection of medium molecules
n Ultrafiltration of water
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Filter Dialysis fluid l High/low patassium l High/low calsium l Bicarbonate
The hemodialysis machine
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Dialysis water
n ”Standard-HD-pas” is exposed to 0,5 l/min x 4 h x 3 x 52 = 18 720 l/yr In the early days of dialysis treatment problems with Al. Bacteria and endotoxins: stimulation of inflamation, decreased response of erythropietin and possibly aggravation of atherosclerosis.
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Blood access Two lumen large bore catheter in neck vein with subcutanous tunnelation
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Can be used 6-8 weeks after the operation
Arterio-venous fistula («short-cut»)
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n ”Needles were the worst thing I could think about, so I never thought I could do this myself. But now, nobody else is allowed to get near my arm……..”
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How much dialysis is enough?
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Kidney transplantation
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n Necro donation n Traffic accidents,
cerebral bleedings n Waitinglist 1-2 years
n Living donation n Parents, siblings,
children n Spouse, good friend n 40 % of all Tx in
Norway n Waitinglist 2-3
months n Better survival of the
new kidney
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1 2 3 4 5 6 7 8
10
20
30
405060
70
80
90100
Graf
t Sur
viva
l %
CD; 1-2 DR mm. N=479
CD; 0 DR mm. N=301LD; non-id. N=738
LD; HLA-id N=101
Years
LD (N=839) vs. CD (N=780): p= 0.0016LD non-id. vs. CD 0 DR mm. : n.s. (p= 0.2157)LD non-id. vs. CD 1-2 DR mm. : p < 0.0001CD 0 DRmm. vs. CD 1-2 DR mm.: p < 0.0001
First renal graft survival in patients below 60y.By donor source and HLA match
Norway 1989-2002
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n Surgery n ”Medium operation” n Low risk of death
n Immunosupression n Prednisolon n Cyclosporin n Cytostaticum
n Acute complications n Acute rejection n Urine leakage, bleeding,
clotting of vessel n Infection in wound, urine,
lungs, sepsis (”blood poisioning” )
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n Benefits over dialysis n Cheaper n Much better quality
of life n Better survival n Less cardiovascular
complications
n Complications n Infections n Loss of transplant
function n Cardiovascular
disease n Cancer
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Prednisolon n Antiinflammatory + immunosupressiv effect n Reduced the production of many cytokines
40 mg x1 reduced to 5 mg x 1
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2.CD28 1.TCR+CD3
Ag
CNI
Calcineurin inhibitors cyclosporin A
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Imurel
n Interfers with DNA synthesis. Built into DNA- og reduces celleproliferation
n Nobel prize 1988
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Halloran P. N Engl J Med 2004; 351:2715-29
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0 12 24 36 48 60 72 84 96 108 120
10 20 30 40 50 60 70 80 90
100
Months
Gra
ft S
urvi
val %
Survival of first CD renal grafts
1992-97
1978-82
1987-91
1983-87
TL
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Summary
n Kidney and urinary tract diseases include n Very frequent and very seldom diseases n Acute and chronic, harmless and deadly n Strong dependence of technical solutions for
evaluation and treatment n Great challenges in the time to come