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Fig 26-3
Ducts within each renal
papilla release urine
into minor calyx
major calyx
renal pelvis
ureter
Histologically, each kidney is composed 1-3 million
uriniferous tubules. Each consists of
Secretory part - which forms urine is called nephron, functional
unit of kidney
Nephrons open in to collecting tubules. Many such tubules unite
to form the ducts of Bellini which open into minor calices
Arterial Supply
One renal artery on each side arising from abdominal aorta
At or near hilus, renal artery divides into anterior and
posterior branches giving rise to segmental arteries
Lymphatics
Lateral aortic nodes
Nerve Supply
Renal plexus (an off shoot of coeliac plexus, T10-L1)
Circulation of renal blood flow
Renal artery divides serially into – interlobar artery arcuate interlobular arteries
afferent arterioles capillary tufts of renal glomeruli into outer cortex efferent arterioles
in juxtamedullary zone arterioles become vasa recta (closely applied to loop of henle)
Venous drainage: Stelate veins interlobular veins arcuate veins interlobar veins
Two types of nephrons are present
Cortical nephrons with short loop of Henle
Juxtamedullary nephrons with long loops of Henle
Glomerulus - Five components
Capillary endothelium – 70-100
nm fenestrations – restricts
Filtration barrier
passage of cells
Glomerular basement membrane
– filters plasma proteins
Visceral epithelium – podocytes
with s foot processes with 25-60
nm gaps, permeability altered by
contraction of foot processes
Parietal epithelium (Bowman’s
capsule)
Mesangium (interstitial cells) –
pericytes, structural support,
phagocytosis, restricts blood flow
in response to angiotensin-II
Filtration barrier - Size and charge selective
Charge: all 3 layers contain negatively charged
glycoproteins restricts passage of other negatively
charge proteins
Size: Molecules with radius <1.8 nm water, sodium,
urea, glucose, inulin freely filtered
>3.6 nm hemoglobin and albumin not filtered
Between 1.8-3.6 cations filtered, anions not
Glomerulonephritis negatively charged glycoproteins
destroyed polyanionic proteins filtered proteinuria
Glomerular Filtration Rate (GFR)
Normal GFR: in men = 125 ml/min, 10% lower in females
Depends on permeability of filtration barrier
Difference between hydrostatic process pushing fluid into
Bowman’s space and osmotic forces keeping fluid in
plasma
GFR = Kuf [(Pgc – Pbs) – (gc – bs)
Pgc & Pbs = Hydrostatic pressure in glomerular capillary
and basement membrane
gc & bs = plasma oncotic pressure in glomerular
capillary and basement membrane
Kuf = Ultrafiltration coefficient reflects capillary permeability
and glomerular surface area
Juxtaglomerular apparatus
Macula densa – modified portion of thick ascending limb
which is applied to glomerulus at the vascular pole between
the afferent and efferent arterioles containing
chemoreceptor cells which sense tubular concentration of
NaCl
Granular cells – Produce renin, which catalyses the
formation of angiotensin modulates efferent and afferent
arterial tone and GFR
Macula densa
+
Juxtaglomerular
cells (smooth muscle
fibers from afferent
arteriole)
= Juxtaglomerular
Apparatus
= Endocrine
system structure
(renin and EPO)
Functions
Nephron regulates
Intravascular volume, osmolality, acid base balance,
excrete the end product of metabolism and drugs
Urine is formed by combination of glomerular
ultrafiltration + tubular reabsorption and secretion
Nephron produces hormones
Fluid homeostasis (renin, prostaglandins, kinins)
Bone metabolism (1,25-dihydroxycholecalciferol)
Hematopoiesis (erythropoietin) – produced by interstitial
cells in peritubular capillary bed (85% stimulus
hypoxia
Tubuloglomerular feedback
GFR
delivery of NaCl to distal tubule
Cl- sensed by macular Densa cells
Release of renin (from afferent arterioles)
Angiotensin
Arteriolar constriction
GFR and RBF
Hormonal Regulation
C. Hereditary Disorders
Alport syndrome
Fabry Disease
GLOMERULONEFRITIS
PROLIFERATIF DIFUS (PGN)
Keadaan Klinik :
• Mula gejala RPGN sangat mirip dengan sindrom nefritik
• Tetapi oligouria dan azotemia lebih menonjol.
• 90% penderita menjadi anefritik dan membutuhkan
dialisis kronis/transplantasi.
• Prognosis lebih baik dari pada mereka dengan
presentase kresen yang lebih tinggi.
• Penggantian plasma berguna pada
beberapapenderita, terutama pasien dengan sindrom
goodpasture.
GLOMERULONEFRITIS
PROGRESIVE CEPAT
Chronic - involvement of
pelvicalyceal system and
parenchyma with prominent
scarring.
Aetiology of acute pyelonephritis
Acute pyelonephritis :
mainly caused by bacterial infectionUrinary tract infection
(Proteus,Klebsiella,Enterobacter, Pseudomonas,Stapylococcus albus).
Invasive procedure :
eg.cystoscopy,catheterization.
GENDER--Incidence higher in women due to short urethra ( Ratio 1: 20)
AND due to close proximity of urethra to anus.
Vesicourethral reflux
Pregnancy
DM,immunosuppression,immunodefisiency.
Pathogenesis
Ascending infection
Bacteria from the LUT KIDNEY
Urethral instrumentation (catheterization, cystoscopy ) act as
a predisposing factor.
Hematogenous spread
Less common
septicemia or infective endocarditis kidney
Obstruction
Outflow obstruction or bladder dysfunction
Causes incomplete emptying and increase residual volume
bacteria multiply without disturbance ascend
upwards to infect the kidney
Non obstructive
Incompetence of Vesicourethral orifice allows bacteria to
ascend the ureter into the pelvis of kidney (vesicourethral
reflux)
Sign and symptoms
It is a chronic tubulointerstitial
inflammation involving renal
parenchyma, pelvis and calyces
associated with scarring.
non-obstructive
reflux nephropathy
Obstructive
posterior urethral valves
Chronic pyelonephritis phatogenesis
Symptoms :
headaches, nausea, vomiting, visual impairment
(scotomas = spots).
Malignant nephrosclerosis focal small
hemorrhages due to essential hypertension
(>300/150 mm Hg)
CHARACTERISTIC LESIONS
DIAGNOSIS
Physical examination :
Benign nephrosclerosis: signs of decreased kidney function
and have elevated protein levels in the urine.
Malignant nephrosclerosis: severe high blood pressure, kidney
failure, and visual disturbances.
Ophthalmoscope damaged blood vessels in the back
of the eye, including bleeding, swelling, and a build-up of
fluid.
The heart may also be enlarged.
Urine tests will show high levels of protein and clumps of red
blood cells.
Blood tests high levels of a protein called renin
produced by the kidneys help control blood pressure.
Computed tomography (CT) scan rule out other
disorders that can cause similar symptoms.
THROMBOTIC
MICROANGIOPATHIES
iii) dari luar yang menekan saluran kemih: tumor sekitar saluran
kemih,hiperplasia prostate, ateri renalis menekan ureter
B) Kelainan neuromaskular
- misal nya akibat spina bifida, paraplegi,
tabes dorsalis, sklerosis multipel.
C) Kehamilan
- terutama jelas pada primipara, terjadi
pelebaran fisiologik pada ureter dan pelvis,
tekanan mekanik akibat uterus membesar.
D) Idiopatik
GAMBARAN MAKROSKOPIK
Flank pain
Abdominal mass
Nausea and vomiting
Urinary tract infection
Fever
Dysuria
Increased urinary frequency
Increased urinary
DIAGNOSA
UNILATERAL BILATERAL
Papillary
carcinoma of
urinary bladder
grows outward
rather than in
Muscle layer is
preserved
Papillary projections
– very diagnostic
KOMPLIKASI
Pyelonephritis
Pyonephrosis
Pyoureter
Gagal ginjal
PENGOBATAN