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Disorders of The Urinary system

General introduction

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Jining medical college

affiliated hospital

qiubo

Tel:15153701881

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Anatomic Structure of The kidney

Retroperitoneally on

the posterior of the

abdomen

11cm long 6cm wide4cm thick

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nephron

nephron

Renal corpuscleglomerulus

Bowman,s capsule

Renal tubule

Proximal tubule

Loop of henle

Distal tubule

Collecting duct

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URINARY SYSTEM

1,000,000nephrons in eachkidney

Formed by the invaginationof a tuft of capillaries into

the blind end of a nephron

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In the outer part of the cortex, have

Corresponding short loop of henle

Cortical nephron

Juxtamedullary nephronIn the inner part of the cortex,

With long loop of henle

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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

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URINARY SYSTEM

Epithelial cells are alsocalled podocytes whichhas large extensions ortrabeculae project outfrom the cell body andembedded in thebasement membranesurrounding a capillary

There are slit poresbetween the adjacenttrabecular, whichcontrol the movementof substances throughthe final layer of the

filter

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PODOCYTE

1process

2pedicels

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URINARY SYSTEM

Mesangium sonsists ofmesangial cell and martrixwhich provide structuresupport for the capillary

Exhibit phagocytic activity

Secrete extraceliular matrixand prostaglandins

May contribute to regulationof blood flow through theglomerular capillaries

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JGA

GFR Renin

Angiotensin

Blood Pressure

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Major Functions of The Kidney

Regulation of osmolality of the body fluid Regulating the volume of the extracellular fluid

Regulating concentrations of electrolytes of theextracellular fluid

Regulation of acid-base balance

Clearance of metabolic waste products (urea, uricacid, creatinine)

Production of special substances (erythropoietin,renin, prostaglandins, and thromboxane)

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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

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Net Filtration Pressure

Blood hydrostatic pressure(BHP) 60 mmHg outColloid osmotic pressure(COP) -32 mmHg inCapsular pressure(CP) -18 mmHg inNet filtration pressure(NFP) 10 mmHg ou

NFP

BHP 60 out

COP 32 in

CP

10 out

18 in

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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

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Tubular reabsorption and secretion

180L ultrafiltration of plasma in adults,but only 1-1.5Lfinal 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 themedulla

Distal tubule: reabsorb of the Na

+

is coupled withreabsorption of Ca 2+ ,Mg 2+ ,and secretion of K+and H+

Collecting duct: regulation of the concentration andvolume of final urine

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Renal endocrine

Rennin

Angiotensin

Prostaglandin

Kinin

Erythropoietin

1hydroxylase

vasoavtive

Regulate renal hemodynamic change

Control the balance of water and salt

nonvasoactiveAct on the general body

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Approach to renal disease

Present with renal disease in two ways:

discovered incidentally, or with evidence of renaldysfunction 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

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Diagnostic TestsUrinalysis

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

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Diagnostic TestsUrinalysis

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

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RBC Cast

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Proteinuria

>150mg/24h Reasons

1. functional proteinria: to be benign process stem from acute illness,exercise, and orthostatic proteinuria

a.usually under 30 years oldb.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 proteinsb.urinary protein elctrophoresis will exhibit a discrete protein peak

c. other examples of overload ptoteinuria include myoglobinuria in

rhabdomyolysis,and hemoglobinuria in hemolysis

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Proteinuria

3. Glomerular proteinuria: from injury of glomerular filtration barrier andaltered 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 inducedinterstitial nephritis, and hereditary metabolic disorder

5. 24h urine collection:>3.5g/d is consistent with nephrotic-rangeproteinuria,but is not easy to execute

The ratio of Urinary protein to Urinary creatinine is correlated with

24-hour urine collection

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hematuria

Extraglomerular

(90%)

glomerular causes

(10%)

cystitis

calculi

interstitial nephritisrenal neoplasm

IgA nephropathy

thin GBM diseasepostinfectious glomerulonephritis

membranoproliferative

glomerulonephritis

systemic nephritic syndrome

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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 correlateswith the ability of kidneys to filter fluids andvarious substances

Can be measured by determining the renal

clearance of plasma substance that are notbound to plasma proteins, and are freely filtrateacross the glomerulus, and are neither secretednor reabsorbed along the renal tubules

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Estimation of GFR

Normal 100-120ml/min Means : inulin creatinine

MDRD formulaGFR =186 x Scr-1.154 x Age -0.203

Cockroft-Gault

(140 - Age) x Weight(Kg)

Scrx72 The ratio of BUN / creatinine 10:1

Ccr(ml/min)=

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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, andto evaluate renovascular disease

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Imaging studies

ultrasonography

Identify the thickness and

echogenicity of the renal cortex,medulla, and pyramids, and

urinary collecting system

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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 functionParticularly useful in diagnosing

medullary sponge kidney and

papillary necrosis

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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

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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

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Arteriography and venography

Arteriography is useful in

evaluation atherosclerotic or

fibrodysplatic stenotic lesions

Venography is the best test for

diagnosis of renal vein thrombosis

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Renal biopsy

Relative contraindication

Solitary or ectopic kidneyUncorrected 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

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Normal Kidney:

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Renal biopsy

Focal segmental glomerular sclerosing nephritis

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Renal biopsy

Mesangial proliferative glomerulonephritis

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Renal biopsy

Immunofluorescence

microscope

Crescentic

glomerulonephritis

There are a lot of fibrin

deposit in the capsule

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Acute renal failure syndrome

Acute rapidly progressive

glomerulonephritis syndrome Acute glomerulonephritis syndrome

Chronic renal failure syndrome

Nephrotic syndrome

Asymptomatic urinary abnormalities

Clinical syndrome of renal disease

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Nephritic Hematuria

Proteinuria

Hypoalbuminemia

Oliguria (GFR, Cr

, BUN) Edema (salt and

water retention)

Hypertension

Nephrotic Proteinuria

(nephrotic range>3.5g/24h)

Hypoalbumimenia

Edema Hyperlipidemia

Lipiduria

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Acute renal failure syndrome

Rapid severe decrease in GFR, usually with reducedurine output

Extracellular fluid expansion leads to edema

hypertension, and occasionally to chronic renal failure Hyperkalemia, hyponatremia, and acidosis are common

Etiologies:

ischemia

nephrotoxic injury

renalvascular diseasepregnancy

prerenal or postrenal ailure

A t idl i

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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 fromasymptomatic infiltrates to life-threating

hemoptysis

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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

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Nephrotic syndrome

Albuminuria

Edema

Hypoalbuminemia

Hyperlipidemia

Complication

severe edema thrombosis events

infection protein malnutrition

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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 oranalgesic 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

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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

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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 becontrolled to 125/75mmHg

Volume control with salt and restiction and diuretics is the mainstayof therapy

With the added consideration of cardioprotective benefit, ACEI andARB are commended firstly

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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 nondiabeticrenal failure, due to their proteinuria-

lowering effect

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over the past 40years, renal replacementtherapy has prolonged the lives of many patientswith end stage renal disease

Hemodialysis Continuous renal replacement therapies Peritoneal dialysis

transplantation

Renal replacement therapy

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Hemodialysis

Heparin (anticoagulant)

Required 3Xs/week for 3-4 hrs

Is the most common therapeutic modalityfor ESRD

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Hemodialysis

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Continuous renal replacement

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Continuous renal replacement

therapy

Severe acute renal failure

Better tolerated hemodynamically

Effective in removing fluid and simple toperform

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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

Peritoneal dialysis

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Most effective treatment

Mycophanolate mofetil,cyclosporin,

leflunomide,and tacrolimus, the mortalityof the patients reduced

Improved lifestyle and improved life

expectancy

transplantation