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Proper function of the renal and urinary system is essential to life. Dysfunction of the kidneys is common
and may occur at any age and with varying degrees of severity. Assessment of the upper and lower
urinary tract function is a part of every health examination and necessitates and a n understanding of
the anatomy and physiology of urinary system as well as the effects and changes in system on other
physiologic function.

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he renal and urinary tract system includes the kidneys, ureters, bladder and urethra. Urine is formed by
the kidney and flows through the other structures to be eliminated from the body.


he kidneys are a pair of bean-shaped, brownish-red structures located retroperitoneally (behind and
outside the peritoneal cavity). he right kidney is slightly lower than the left due to the location of the
liver.

Externally, the kidneys are well protected by ribs and by the muscles of the abdomen and back.
Internally, fat deposits surround each kidney, providing protection against jarring. he kidneys and
surrounding fat are suspended from the abdominal wall by renal fascia made of connective tissue. he
fibrous connective tissue, blood vessels, and lymphatics surrounding each kidney are known as renal
capsule.

he renal parenchyma is divided into two parts; the cortex and the medulla. he medulla, which is
approximately 5 cm wide, is the inner portion of the kidney. he cortex, which is approximately 1 cm
wide, is located farthest from the center of the kidney and around the outermost edges.

 
he hilum, or pelvis, is the concave portion of the kidney through which the renal artery enters and
ureters and renal veins exit. he kidneys received 20% to 25% of the total cardiac output, which means
that all of the body͛s blood circulates through the kidneys approximately 12 times per hour. he renal
artery (arising from the abdominal aorta) divides into smaller and smaller vessels, eventually forming
the afferent arterioles. Each afferent arteriole branches to form a glomerulus, which is the capillary bed
responsible for glomerular filtration. Blood leaves the glomerulus through the efferent arteriole and
flows back to the inferior vena cava through a network of capillaries and veins.



Each kidney has 1 million nephrons, which usually allows for adequate renal function even if the
opposite is damaged or becomes nonfunctional. he nephrons are the structures located within the
renal parenchyma that are responsible for urine formation.
here are two kinds of nephrons. he cortical nephrons, which make up 80 to 85 % of the total
number,aree located in the outermost part of te cortex, and the juxtamedullary nephrons, which make
up the remaining 15% to 20 % are located deeper in the cortex. he juxtamedullary nephrons are
distinguished by long loops of Henle, which are surrounded by long capillary loops calle dvasa recta that
dip into the medulla of the kidney.

Nephrons are made up of two basic components: a filtering element composed of an enclosed capillary
network (the glomerulus) and the attached tubule. he glomerulus is a unique network of capillaries
suspended between the afferent (ingoing) and small efferent (outgoing) arteriole, which are enclosed in
an epithelial structure called Bowman͛s capsule. he glomerular membrane is composed of three
filtering layers: the capillary endothelium, the basement membrane, and the epithelium. his membrane
normally allows filtration of fluid and small molecules yet limits passage of larger molecules, such as
blood cells and albumin. Pressure changes and the permeability of the glomerular membrane of
Bowman͛s capsule facilitate the passage of fluids and various substances from the blood vessels, filing
the space within Bowman͛s capsule with this filtered solution.

he tubular component of the nephron begins in the Bowman͛s capsule. he filtrate created in the
Bowman͛ s capsule travels first into the proximal tubule, then the loop of Henle, the distal tubule, and
either the cortical or medullary collecting ducts. he distal tubular cells located in this area, known as
the macula densa, function with the adjacent afferent arteriole and create what is known as the
juxtaglomerular apparatus, the site of renin production.



  
 
he healthy human body is composed of approximately 60% water. Water balance is regulated by the
kidneys and results in the formation of urine. Urine is formed in the nephrons through a complex three-
step process: glomerular filtration, tubular reabsorption, and tubular secretion. he various substances
normally filtered by the glomerulus, reabsorbed by the tubules and excreted in the urine include
sodium, chloride, bicarbonate, potassium, glucose, urea, creatinine, and uric acid. Within the tubule,
some of these substances are selectively reabsorbed into the blood. Others are secreted from the blood
into the filtrate as it travels down the tubule.

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he normal blood flow through the kidney is about 1200 mL/ min. As blood flows into the glomerulus
from an afferent arteriole, filtration occurs. hen filtered fluid, also known as filtrate or ultrafiltrate,
then enter the renal tubules. Under normal conditions, about 20% of the blood passing through the
glomeruli is filtered into the nephron, amounting to about 180 L/day of filtrate. he filtrate normally
consists of water, electrolytes, and other small molecules, because water and small molecules stay in
the bloodstream.
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he second and third steps of urine formation occur in the renal tubules. In tubular reabsorption, a
substance moves from the filtrate back into the peritubular capillaries or vasa recta. In tubular secretion,
a substance moves from the peritubular capliiaries or vasa recta into tubular filtrate. Of 180 L (45
gallons) of filtrate that the kidneys produce each day, 99% is reabsorbed into the bloodstream, resulting
in the formation of 1000 to 1500 mL urine each day. Reabsorption and secretion in the tubule frequently
involve passive and active transport and may require the use of energy.

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Antidiuretic hormone (ADH), also known as vasopressin, is a hormone that is secreted by the posterior
portion of pituitary gland in response to changes in osmolality of the blood. With decreased water
intake, blood osmolality tends to increase, stimulating ADH release. ADH then acts on the kidney,
increasing reabsorption of water and thereby returning osmolality of the blood to normal. With excess
water intake, the secret of ADH by pituitary is suppressed; therefore less water is reabsorbed by the
kidney tubule.






Osmolarity refers to the ratio of solute to water. he regulation of salt and water is paramount for
control of the extracellular volume and both serum and urine osmolarity. Controlling either the amount
of water or the amount of solute can change osmolarity. Osmolarity and ionic compositions are
maintained by the body within very narrow limits. As little as a 1% to 2 % change in the serum
osmolarity can cause a conscious desire to drink and conservation of water by the kidneys.

he degree of dilution or concentration of the urine is also measured in terms of osomolality, the
number of osmoles (the standard unit of osmotic pressure) dissolved per kilogram of solution. he
filtrate in the glomerular capillary normally has the same osmolality as the blood, 275 to 300 mOsm/kg.

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Regulation of water excreted is an important function of the kidney. A person normally ingests about
1300 mL of oral liquids and 100mL of water I food per day. Of the fluid ingested, approximately 900 mL
is lost through the skin and lungs (insensible loss), 50 mL through sweat, and 200 mL through feces. It is
important to consider all fluid gained and lost when evaluating total fluid status. Daily weight
measurements are a reliable means of determining overall fluid status. One pound equals approximately
500 mL, so a weight change of little as 1 lb could suggest an overall fluid gain or loss of 500 mL.

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When the kidneys are functioning normally the volume of electrolytes excreted per day is equal to the
amount ingested.

SODIUM

Normal serum sodium levels are between 135 to 145 mmol/L. Approximately 90% of the sodium
contained in the renal filtrate is reabsorbed in the proximal tubules and loop of Henle.
he regulation of sodium volume excreted depends on aldosterone, a hormone synthesized and
released from the adrenal cortex. With increased aldosterone in blood, less sodium is excreted in the
urine, because aldosterone fosters renal reabsorption of sodium.

POASSIUM

he kidneys are responsible for excreting more than 90% of the total daily potassium intake. Several
factors influence potassium loss through the kidneys. Aldosterone causes the kidneys to excrete
potassium, in contrast to its effects on sodium described previously, the acid base balance, the amount
of the dietary potassium intake, and the flow rate of the filtrate in the distal tubule also influence te
amount of potassium secreted into the urine.

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he normal serum pH is about 7.35 to 7.45 and must be maintained within this narrow range for optimal
physiologic function. he kidney performs two major functions to assist in this balance. he first is to
reabsorb to the body͛s circulation any bicarbonate from the urinary filtrate; the second is to excrete acid
in the urine. Because bicarbonate is a small ion, it is freely filtered at the glomerulus. he renal tubules
actively reabsorb most of the bicarbonate in the urinary filtrate. o replace any bicarbonate, new
bicarbonate is generate by the renal tubular cells through a variety of chemical reactions. his newly
generated bicarbonate is then reabsorbed by the tubules and returned to the body.

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Specialized blood vessel of the kidney, called vasa recta, constantly monitor blood pressure as blood
begins its passage into the kidney. When the vasa recta detect a decrease in blood pressure, specialized
juxtaglomerular cells near the afferent arteriole, distal tubule, and efferent arteriole secrete the
hormone renin. Renin converts angiotensinogen to angiotensin I, which is then converted to angiotensin
II, the most powerful vasoconstrictor known; angiotensin II causes the blood pressure to increase. he
adrena cortex secretes aldosterone in response to stimulation by pituitary gland, which occurs in
response to poor perfusion or increasing serum osmolality. he result is an increase blood pressure.
When the vasa recta recognize he increase in blood pressure, rennin secretion stops. Failure of this
feedback mechanism is the primary case of hypertension.

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he kidneys excrete water soluble waste products and other chemicals or substances from the body.
his process is called renal plasma clearance, which refers to the ability of the kidneys to clear a given
amount of plasma of a particular substance in a given time (usually 1 minute) the kidneys clear 25 to 30
g of urea ( a nitrogenous waste product formed in the liver from the breakdown of amino acids) each
day. hey also clear creatinine(an end product of creatinine phosphate, found in skeletal muscle), uric
acid (a metabolic of nucleic acid metabolism), and ammonia as well as bacterial toxins and water-soluble
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When the kidneys sense a decrease in the oxygen tension in renal blood flow, they release
erythropoietin. Erythropoietin stimulates the bone marrow to produce a red blood cells (RBCs), thereby
increasing the amount of hemoglobin available to carry oxygen.

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he kidneys are also responsible for the final conversion of inactive Vitamin D to its active form, 1.25
dihydroxycholecalciferol. Vitamin D is necessary for maintaining normal calcium balance in the body.

   

 
he kidneys also produce prostaglandin E and prostacyclin, which have a vasodilatory effect and are
important in maintaining renal blood flow.

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he kidney functions as the body͛s main excretory organ, eliminating the body͛s metabolic waste
products. he major waste product of protein metabolism is urea, of which about 25 to 30 g are
produced and excreted daily. All of this urea must be excreted in the urine; otherwise it accumulates in
body tissues. Other waste products of metabolism that must be excreted are creatinine, phosphates,
and sulfates. Uric acid, formed as a waste product of purine metabolism, is also eliminated in the urine.
he kidneys serve as the primary mechanism for excreting drug metabolites.