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Nephrologi: - PWM Olly Indrajani - 18-3-2015
Nephrologi: - PWM Olly Indrajani - 18-3-2015
• 18-3-2015
3 Functions of the Urinary System
1. Excretion:
– removal of organic wastes from body fluids
2. Elimination:
– discharge of waste products
3. Homeostatic regulation:
– of blood plasma volume and solute
concentration
Urinary organs
Organs:
1. Ren
2. Ureter
3. Vesica urinaria
4. Urethra
Kidneys
• Organs that excrete urine
Urinary Tract
► Organs that eliminate urine:
ureters (paired tubes)
urinary bladder (muscular sac)
urethra (exit tube)
Kidneys
• Feature like soya bean; 11 X 6 X 3 cm, weight=±150
gr (♂) and ±135 gr (♀); smooth surface
(fetuslobulated); lower pole is palpable in full
inspiration (thin individu)
• Position:
– Regio abdomen posterior.
– Lateral columna vertebra
– Retroperitoneal.
– Between Vertebra T.XII – Vertebra L.III
– Ren dextra usually slightly inferior than sinistra (why?)
Position of the kidneys
Renal projection
Renal relations syntopi
Renal protection
1. Renal projection
• Anterior:
– Hilum: 5cm from midline,
medial from the tip costae
9th
• Dex: under transpyloricum
plane
• Sin: over transpyloricum
plane
• Posterior:
– Hilum: lower border of
processus spinosus
vertebrae lumbalis 1st &
±5 cm from midline.
3. Renal protection
1. Capsula renalis
– Collagen fibers covers outer surface organ
2. corpus adiposum perirenalis/capsula
adiposa/perirenal fat
– Adipose tissue surround renal capsule (
connected by trabeculae, >>ren inferior)
3. Fascia renalis
– fibrous outer layer anchors kidney to
surrounding structures
4. Corpus adiposum pararenalis/pararenal fat
– Adipose tissue posterior to fascia renalis
Renal Blood Vessels
Arteri Renalis
• A. renalis gives:
– a. suprarenalis inferior
• note: a. supraneralis superior and media from a. phrenica inferior and
aorta abdominalis
– Branches to the perinephric tissue, renal capsule, pelvis and
proximal part of the ureter
• Near the hilum a. renalis divides into divisi anterior and divisi
posterior a. segmentalis
Variation:
– A. renalis accesorius arise from aorta (30%) and rarely from a. colica, a.
mesenterica superior, or a. iliaca communis
• A. renalis a. segmentalis
– Renal vascular segmentation (by Graves 1956)
1. Apical
2. Superior (anterior)
3. Inferior
4. Middle (anterior)
5. Posterior
• A. lobaris (one for each pyramid) divides into 2-3
a. interlobaris a. arcuata
• a. interlobularis
– diverge radially into the cortex
– Some perforate surface as perforating artery rami
capsulares
• a. afferent a. efferent
– peritubular capillary plexus (around PCT & DCT in the
cortical nephron)
– vasa recta (arteriolae rectae in the juxtamedullary
nephron)
• v. interlobularis
Renal structures
1. Hilus renalis
2. Sinus renalis
3. Capsula renalis
4. Cortex renalis
5. Medulla renalis
a. Pyramida renalis
Papilla renalis (ductus Bellini)
b. Columna renalis (columna Bertini)
6. Lobus renalis
7. Calyx minor Calyx major
8. Pelvis renalis
Fig. Renal structures
Left-right orientation (dorsal view)
Anterior:
V.renalis but branch of
vein exit for hilum
posterior of pelvis renalis
Medial:
A.renalis but branch of
artery entry for hilum
posterior pelvis renalis
Posterior:
pelvis renalis
Nephron
(functional subunit of the kidney
Filtration membrane
• Capillary endothelium
(fenestrated capillaries)
• Lamina basalis
• Modified of visceral
epithelium (podocyte)
proc. Primer proc.
Secondary (pedicels)
filtration slits
Tubulus renalis
Consists of:
1. Tubulus contortus
proximal (PCT)
2. Loop of Henle
• Descending limb
• Ascending limb
3. Tubulus contortus distal
(DCT)
Located on:
• Cortex: PCT & DCT
• Medulla: Loop of Henle
JUXTA GLOMERULAR APPARATUS (JGA)
Location:
Near each renal
corpuscel’s vascular
pole, at the point of
contact between a distal
convoluted tubule and
an afferent arteriole.
JUXTA GLOMERULAR APPARATUS (JGA)
Consists of:
– Juxta glomerular (JG cell)
• Modified smooth muscle cell in the afferent arteriole’s
wall
• Function: secrete renin
– A macula densa
• Modified from DCT
• Function: homeostasis
– Polkissen cells (extraglomerular mesangeal
cells)
• Function: maybe phagocyte
Mesangeal cell
• Located between 2 glomerulus, where they have 1
basement membrane (membrana basalis)
• The function maybe as a phagocyt
• concentrated between capillaries at the vascular pole of the
corpuscle
URETER
P
a
rs
a
b
d
o
m
in
al
Pars pelvica
Ureter
• Pars abdominal
– Posterior to the peritoneum
– Medial to anterior of m. psoas major
– Crosses anterior n. genitofemoralis
– Obliquelly crossed by a/v. testicularis (ovarica)
• Pars pelvica
– Posterolaterally on the lateral wall of pelvis minor,
along anterior border of incisura ischiadica major
until spina ischiadica and turns anteromedially into
fibrous adipose tissue above m. levator ani to reach
base of vesica urinaria.
NOTE:
• Male ureter:
– Crossed anterosuperiorly from
lateral to medial by ductus deferens
– Anterior to the upper pole of
vesicula seminalis
URINARY BLADDER (Vesica urinaria)
• Empty: tetrahedral / pyramid in shape
– Apex: anterior, connected by urachus to the umbilicus.
– Basis/fundus (posterior surface):
• Male: related to the rectum separated by rectovesical pouch
• Female: related to the anterior wall of vagina & cervix of uterus
separated by vesicouterine pouch
– Superior surface: covered by peritoneum, in female
posteriorly related to the cervix & corpus uteri.
– Inferolateral surface: separated by the adipose retropubic
pad from pubis and lig. puboprostatic/pubovesical.
• Fills: ovoid
– above umbilicus
The Trigone of the Urinary Bladder
(trigonum vesicae Lieutaudi)
Nerve supply of VU
Plexus vesicalis:
T10-L2 sympathetic
S2-S4 parasympathetic
Urethrae
►Male urethrae
►Female urethrae
The Urethra
• Extends from neck of urinary bladder
• To the exterior of the body
Pars spongiosa
Anatomy of prostate gland
• Basis (pierced centrally by urethrae); apex; facies anterior
(convex); facies posterior (concave); 2 of facies infero-lateral
• Colliculus seminalis
(verumontanum) is
used to determine
the position of
prostate gland
during TURP
The Female Urethra
• Is very short (3–5 cm)
• Extends from bladder to vestibule
• External urethral orifice (ostium urethrae
externum) is near anterior wall of vagina
• Epithel: transitional stratified-squamous
The External Urethral Sphincter
(M. sphincter urethrae externa)
• In both sexes:
– is a circular band of skeletal muscle
– where urethra passes through urogenital diaphragm
• Acts as a valve
• Is under voluntary control:
– via perineal branch of pudendal nerve
• Has resting muscle tone
• Voluntarily relaxation permits micturition
TOPICS :
1. Renal Failure
2. Glomerular diseases
3. Diseases affecting tubules and interstitium
* Acute tubular necrosis
* Pyelonephritis
4. Tumor
* Tumor of the kidney :
- Wilm’s tumor, Grawitz tumor
* Tumor of the bladder :
- Urothelial Tumor
5. Prostate
* BPH
* Ca of the Prostate
RENAL FAILURE :
# Diminution or loss of renal function
* GFR ↓ BUN , creatinine (azotemia)
clinical manifestation (+) uremia
1. Immunologic mechanism :
a. Trapped of circulating Ag – Ab complexes within
glomerulus
b. In situ, as react of Ab with :
* intrinsic antigens (GBM Anti GBM nephritis)
* extrinsic antigens that planted within glomerulus
2 Non immunologic mechanism :
• Any renal disease that destroys functioning nephrons
GFR↓ to ± 30 – 50% of N
capillary hypertrophy & hypertension
(+systemic)
* epithelial & endothelial damage
proteinuria
* proliferation of mesangial cells & increased
accumulation of extracellular matrix
glomerulosclerosis
CLINICAL MANIFESTATION OF GLOMERULAR
DISEASES
1. Acute nephritic syndrome
2. Nephrotic syndrome
3. Rapidly progressive GN (Acute nephritis, proteinuria,
ARF)
4. Chronic renal failure
5. Asymptomatic hematuria or proteinuria
Nephrotic RPGN
Asymptomatic Nephritic
Hematuria / syndrome
syndrome
Proteinuria
End stage
Diminished Renal Late stage
Reserve RF
Renal Early
Insufficiency stage RF
Uremia (P+ abnormalities):
Pre Uremia (P) *Cardiopulmonary
Mild Azotemia (A) (A)+ Acidosis *Hematologic
Hypocalcemia *Gastrointestinal
Hyperkalemia *Dermatologic
*Neuromuscular
Clinical manifestation of glomerular disease
Nephritic Syndrome
a clinical complex, usually of acute onset, characterized by
1. hematuria with dysmorphic red cells and red blood cell
casts (silinder) in the urine,
2. some degree of oliguria and azotemia, and
3. Hypertension
lesions characteristic: proliferative changes and
leukocyte infiltration
produced by : systemic disorders such as SLE,
primary glomerular disease (as Acute
Postinfectious /Poststreptococcal
Glomerulonephritis )
ACUTE NEPHRITIC SYNDROME :
* Oliguria
* Hematuria
* Erythrocyte cast
* Proteinuria
* Azotemia
* Mild to moderate hypertension
* Mild edema
Post Streptococcal GN
# 1 – 4 weeks after a streptococcal infection
of the pharynx or skin (impetigo)
# AS0 titer ↑
# Serum complement level ↓
# Morphology :
* Diffuse enlarged & hypercellular glomeruli, caused by :
- proliferation of endothelial & mesangial cells
- Infiltration by neutrophils and monocytes
- Crescent formation (in severe cases)
- IF : granular deposits of IgG, IgM and C3
- ME : electron dense deposits (subepithelial)
# Prognosis : - 95% total recovery
- others : RPGN / CGN CRF
Rapidly Progressive (Crescentic) GN
# Etiology :
* Anti GBM disease IF : linear dep.of IgG, C3
* Immune complex disease IF : granuler
(complication of PSGN, SLE etc)
* Pauci-immune : Wegener granulomatosis, idiopathic
# Morphology :
- The kidneys are enlarged & pale
- Petechiae on the cortical surfaces
- Glomeruli :
- Focal necrosis
- Diffuse/focal endothelial & mesangial
proliferation
- Proliferation of parietal cells & migration of
monocytes, macrophages, neutrophils,
lymphocytes crescent
obliterate Bowman space
Nephrotic Syndrome
a clinical complex that includes :
Permeability of GBM
Proteinuria
Hypoalbuminemia
Capillary osmotic
pressure ↓ Serum lipid
ADH GFR ↓
Aldosteron RPF ↓
Na++ H2o
retention
Characteristic:
- glomeruli have a normal appearance
(light microscope)
- diffuse effacement of podocyte foot processes
(electron microscope)
Age: any age , most common 1 -7 yo
Pathogenesis
involves some immune dysfunction → resulting in the
elaboration of a cytokine that damages visceral
epithelial cells and causes proteinuria.
Focal Segmental Glomerulosclerosis
(1) (2)
VASO CONSTRICTION OBSTRUCTION (3)
RENIN – ANGIOTENSIN BY CAST S TUBULAR
BACK-LEAK
(4)
DIRECT GLOMERU GFR OLIGURIA
LAR - EFFECT
2. Refluks Nephropathy
- Infection from VU reflux the kidney
- Bilateral / unilateral.
Types of Chronic Pyelonephritis
1. Chronic Obstructive PN
- Obstruction predisposes to infection
- Recurrent infections superimposed on diffuse
or localized obstructive lesion scarring
picture of CPN
- Obstruction parenchymal atrophy
- Bilateral / unilateral
2. Refluks Nephropathy
- Infection from VU reflux the kidney
- Bilateral / unilateral.
Clinical course :
- Insidious in onset / acute recurrent with back
pain, fever, pyuria and bacteriuria
- Loss of tubular function polyuria & nocturia
- CPN is a result of superimposed bacterial
infection in obstructive urine or vesicoureteral
reflux (CPN rarely caused by
bacterial infection alone)
Clear Cell Ca :
- Tumor cells : rounded / polygonal
- Abundant clear / granular cytoplasm
- Tubular / solid / trabecular
- Most tumor : well differentiated
- Some tumors show marked nuclear atypia,
bizzare nuclei and giant cells
Clinical course :
* Classic diagnostic features :
- Costovertebral pain, palpable mass & hematuria
* Others :
- Fever, malaise, weight loss
- Paraneoplastic syndrome (abN hormone
production)
- polycytemia, hypercalcemia, hypertension,
feminization/masculinization, Cushing syndrome,
eosinophilia, leukemoid reactions, amyloidosis
- Tendency to metastasize widely before giving rise
to any local symptoms or signs
* The most common locations of metastasis :
- lung (50%), bone (23%), lmn, adrenal,
liver, brain
MICROS :
* Grade I : - close resemble N transitional cells
- mitosis ±, number of layer >, slight loss of
polarity
* Grade II : - mitosis >, layers >>, greater loss of polarity
* Grade III :- mitosis>>, layers >>>, polarity (-)
- anaplastic, giant cells (+)
PROSTATE
• Retroperitoneal organ
• Encircling the neck of the bladder & urethra
• Pear-shaped
• Weight (normal adult male) : ± 20 gr
• Divided into 5 lobes :
- posterior, middle, anterior, lateral (2)
• 2 component :
- tubuloalveolar gland
- fibromuscular stroma
BENIGN PROSTATIC HYPERTROPHY /
HYPERPLASIA
• >>50 y.o
• Hyperplasia : stromal & epithelial
discrete nodule in the periurethral region
compress & narrow the urethral canal
obstruction (partial / complete)
• Insidence :
- 40 y.o : ± 20%
- 60 y.o : ± 70%
- 70 y.o : ± 90%
Pathogenesis Testosteron
Stromal Cell Epithelial Cell
T
T
5-reductase tipe 2
DHT
Androgen
receptors
Nukleus
Growth
factor
Growth
factor
Growth factor
receptors
Clinical Course
1. Compression of the urethra
difficulty in urination
2. Retention of urine in the bladder
distention, hypertophy, infection
cystitis & pyelonephritis
3. Frequency, nocturia, difficulty in starting &
stopping the stream of urine, overflow dribbling &
dysuria
4. Acute urinary retention catheterization
5. Residual urine → infection → pyelonephritis
6. Hydronephrosis, azotemia, uremia
Treatment
• Trans Urethral Resection (TUR)
• Open Prostatectomy
TUR
BPH
CARCINOMA of the PROSTATE
Insidence :
• Disease of men 50 y.o; 50 y.o : 1%
• > 300.000 new cases / yr, 41.000 lethal
• << in Asians, age-adjusted insidence :
- Japanese : 3-4 / 100.000
- Hong Kong : 1 / 100.000
- USA (whites) : 50-60 /100.000
Etiology : ?
Risk Factors :
• age, race, family history, genetics, hormonal
(androgens/testosterone), environmental (fat
intake)
Clinical Staging
Stage A : No palpable lesion
A1 : Focal
A2 : Diffuse
Stage B : Confined to prostate
B1 : Small, discrete nodule
B2 : Large or multiple nodules or areas
Stage C : Localized to periprostatic area
C1 : No involvement of seminal vesicles, tumor ≤ 70 g
C2 : Involvement of seminal vesicles, tumor > 70 g
Stage D : Metastatic disease
D1 : Pelvic lymph node metastasis or urethral
obstruction causing hydronephrosis
D2 : Bone or distant lymph node or organ
or soft tissue metastases
Clinical Course