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8/14/2019 Urinology
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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
8/14/2019 Urinology
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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