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SISTEMA URINARIA

SISTEMA URINARIA. Ginus Partadiredja Bagian Fisiologi FK UGM. SISTEMA URINARIA. Fungsi ginjal (ren) Anatomi ginjal Proses produksi urine Filtrasi oleh glomerulus Reabsorbsi oleh tubulus Sekresi oleh tubulus Evaluasi fungsi ginjal Transportasi, penyimpanan, dan ekskresi urine.

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SISTEMA URINARIA

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  1. SISTEMA URINARIA Ginus Partadiredja Bagian Fisiologi FK UGM

  2. SISTEMA URINARIA • Fungsi ginjal (ren) • Anatomi ginjal • Proses produksi urine • Filtrasi oleh glomerulus • Reabsorbsi oleh tubulus • Sekresi oleh tubulus • Evaluasi fungsi ginjal • Transportasi, penyimpanan, dan ekskresi urine

  3. Fungsi ginjal: • Regulasi komposisi ion darah • Regulasi pH darah • Regulasi volume darah • Regulasi tekanan darah • Pemeliharaan osmolaritas darah (300 mOsm/l) • Produksi hormon (calcitriol & erythropoetin) • Regulasi tingkat glukosa darah • Ekskresi sampah benda asing

  4. Anatomi Ginjal • Anatomi eksternal: • Retroperitoneal • Renal fascia • Adipose capsule • Renal capsule • Renal hilum http://images.google.co.id/imgres?imgurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/f27-9a_urinary_bladder_c.jpg&imgrefurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/Urinary%2520System.htm&h=490&w=800&sz=135&hl=id&start=3&tbnid=PjiUmIL-b7BE7M:&tbnh=88&tbnw=143&prev=/images%3Fq%3Dmicturition%2Breflex%26svnum%3D10%26hl%3Did%26lr%3D%26sa%3DG http://www.netterimages.com/images/vtn/000/000/002/2122-150x150.jpg

  5. Nephroptosis (Ginjal melayang/ mengambang) • Orang amat kurus  kapsula adiposa & fasia renalis berkurang  ginjal turun dari posisi normal • Akibat: ureter tertekuk  blokade urine & sakit • Insidensi: 1 dari 4 orang  kelemahan jaringan fibrosa • Perempuan 10 X > Laki-laki

  6. Anatomi Ginjal • Anatomi internal • Cortex renalis • Medulla renalis • Pyramid renalis • Papilla renalis • Collumna renalis • Ductus papillaris • Calyx minor • Calyx major • Pelvis renalis • Sinus renalis http://images.google.co.id/imgres?imgurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/f27-9a_urinary_bladder_c.jpg&imgrefurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/Urinary%2520System.htm&h=490&w=800&sz=135&hl=id&start=3&tbnid=PjiUmIL-b7BE7M:&tbnh=88&tbnw=143&prev=/images%3Fq%3Dmicturition%2Breflex%26svnum%3D10%26hl%3Did%26lr%3D%26sa%3DG

  7. http://kidney.niddk.nih.gov/kudiseases/pubs/solitarykidney/images/nephronkidA.gifhttp://kidney.niddk.nih.gov/kudiseases/pubs/solitarykidney/images/nephronkidA.gif

  8. http://images.google.co.id/imgres?imgurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/f27-9a_urinary_bladder_c.jpg&imgrefurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/Urinary%2520System.htm&h=490&w=800&sz=135&hl=id&start=3&tbnid=PjiUmIL-b7BE7M:&tbnh=88&tbnw=143&prev=/images%3Fq%3Dmicturition%2Breflex%26svnum%3D10%26hl%3Did%26lr%3D%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/f27-9a_urinary_bladder_c.jpg&imgrefurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/Urinary%2520System.htm&h=490&w=800&sz=135&hl=id&start=3&tbnid=PjiUmIL-b7BE7M:&tbnh=88&tbnw=143&prev=/images%3Fq%3Dmicturition%2Breflex%26svnum%3D10%26hl%3Did%26lr%3D%26sa%3DG

  9. Nephron: 1. Renal corpuscle : a. Glomerulus b. Bowman’s capsule 2. Renal tubule: a. Proximal convoluted tubule b. Loop of Henle c. Distal convoluted tubule Collecting duct Papillary duct http://www.farmakologija.com/materia/images/nephron.gif http://coe.fgcu.edu/faculty/greenep/kidney/glomer3.jpg

  10. Vaskularisasi Ginjal • Renal arteryRenal vein • Segmental arteries • Interlobar arteriesInterlobar veins • Arcuate arteriesArcuate veins • Interlobular arteriesInterlobular veins Peritubular venules • Afferent arterioles Peritubular capillaries • Glomerular capillariesEfferent arterioles Vasa recta http://www.geocities.com/biology_4e/cross_section_of_kidney.jpg

  11. http://images.google.co.id/imgres?imgurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/f27-9a_urinary_bladder_c.jpg&imgrefurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/Urinary%2520System.htm&h=490&w=800&sz=135&hl=id&start=3&tbnid=PjiUmIL-b7BE7M:&tbnh=88&tbnw=143&prev=/images%3Fq%3Dmicturition%2Breflex%26svnum%3D10%26hl%3Did%26lr%3D%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/f27-9a_urinary_bladder_c.jpg&imgrefurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/Urinary%2520System.htm&h=490&w=800&sz=135&hl=id&start=3&tbnid=PjiUmIL-b7BE7M:&tbnh=88&tbnw=143&prev=/images%3Fq%3Dmicturition%2Breflex%26svnum%3D10%26hl%3Did%26lr%3D%26sa%3DG

  12. Ginjal = 0.5% total body mass • 20-25% cardiac output istirahat via arteri renalis • Renal blood flow = 1200 mL/ menit

  13. PROSES PRODUKSI URINE • Filtrasi oleh glomerulus • Reabsorbsi oleh tubulus • Sekresi oleh tubulus http://www.colorado.edu/eeb/web_resources/cartoons/nephr.gif

  14. Filtrasi oleh Glomerulus • Filtrat glomerular = 150 l (F)/ 180 l (M); Fraksi filtrasi (16-20%); 99% filtrat direabsorbsi (ekskresi 1-2 l) • Net filtration pressure (NFP) • Glomerular blood hydrostatic pressure (GBHP) = 55 mmHg • Capsular hydrostatic pressure (CHP) = 15 mmHg • Blood colloid osmotic pressure (BCOP) = 30 mmHg NFP = GBHP – CHP – BCOP = 10 mmHg

  15. Glomerular Filtration Rate (GFR): jumlah filtrat • terbentuk di dalam corpusculi renalis per menit = • 125 ml/min (M) atau 105 ml/min (F) • Regulasi GFR • Autoregulasi renal • Mekanisme myogenik • Umpan balik tubuloglomerular • Regulasi saraf simpatis • Regulasi hormonal • Angiotensin II • Atrial natriuretic peptide (ANP)

  16. Autoregulasi renal • Mekanisme myogenik: • BP  RBF  GFR  regangan arteriola afferent  • kontraksi otot arteriola afferent  lumen menyempit  • GFR ke tingkat semula • Umpan balik tubuloglomerular: • BP  GFR  cairan lewat cepat di tubulus  • rebasorbsi Na, Cl, air di PCT & loop of Henle  • deteksi oleh macula densa  inhibisi sekresi NO  • arteriola afferen konstriksi  RBF  GFR ke normal

  17. http://images.google.co.id/imgres?imgurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/f27-9a_urinary_bladder_c.jpg&imgrefurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/Urinary%2520System.htm&h=490&w=800&sz=135&hl=id&start=3&tbnid=PjiUmIL-b7BE7M:&tbnh=88&tbnw=143&prev=/images%3Fq%3Dmicturition%2Breflex%26svnum%3D10%26hl%3Did%26lr%3D%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/f27-9a_urinary_bladder_c.jpg&imgrefurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/Urinary%2520System.htm&h=490&w=800&sz=135&hl=id&start=3&tbnid=PjiUmIL-b7BE7M:&tbnh=88&tbnw=143&prev=/images%3Fq%3Dmicturition%2Breflex%26svnum%3D10%26hl%3Did%26lr%3D%26sa%3DG

  18. 2. Regulasi saraf simpatis  norepinephrine • istirahat: stimulasi rendah arteriola a & e dilatasi  autoregulasi • renal & GFR tetap • stimulasi moderat: arteriola a & e konstriksi  restriksi aliran darah masuk & keluar glomerulus  GFR sedikit • stimulasi kuat: vasokonstriksi arteriola a > e  RBF  GFR  urine •  aliran darah ke jaringan lain

  19. Prinsip-prinsip Reabsorbsi & Sekresi Tubulus • Reabsorbsi: 99% air dikembalikan ke darah • Tubulus proximalis berperan besar dalam reabsorbsi • Reabsorbsi: Na+, K+, Ca2+, Cl- , HCO3- , HPO42- • Protein & peptida  reabsorbsi pinositosis • Tubulus distalis  “fine tuning” reabsorbsi • Sekresi: H+, K+, NH4+, kreatinin, obat-obatan (penisilin) • Sekresi H+ kontrol pH darah • Sekresi substansi sampah • Rute reabsorbsi: • Paraseluler & Transeluler • Mekanisme transport: • Transport aktif primer (hidrolisis ATP) • Transport aktif sekunder (symporters & antiporters) • Transport maksimum (mg/min)  glukosa darah > 200 mg/ml

  20. 90% air direabsorpsi bersama Na+, Cl-, dan glukosa  reabsorpsi air wajib(obligatory water reabsorption) • 10% air (10 – 20 L/ hari) direabsorpsi (tubulus kolektivus, oleh ADH)  reabsorpsi air fakultatif (facultative water reabsorption)

  21. Substansi Terfiltrasi, Direabsorpsi, & Diekskresikan ke Dalam Urine * Dengan asumsi GFR = 180 l/ hari; **Selain difiltrasi & direabsorpsi, urea disekresi; ***K+ difiltrasi & semua direabsorpsi oleh tubulus kontortus & ansa Henle, & disekresi oleh sel principal duktus kolektivus

  22. Rebasorbsi & Sekresi di Tubulus Proximalis http://people.eku.edu/ritchisong/554images/proximal_tubule.jpg • Reabsorbsi ion (terutama Na+ dan air terbesar; 65%) • Reabsorbsi dng sistem Na+ symport: glukosa & asam amino • (100%), asam laktat, ion-ion fosfat (HPO42-) dan sulfat (SO42-) • Sistem Na+ /H+ antiport: Na+dan HCO3- (80-90%) • Osmosis air (tub. prox. & descending limb of Henle -> permeable) • Difusi pasif: Cl- (50%),K+ (65%), Ca2+, Mg2+, HPO42+ • Hepatosit: Ammonia (NH3)  urea  filtrasi & sekresi • Deaminasi asam amino  ammonia

  23. Reabsorbsi di Loop of Henle • Akhir tubulus proximalis: osmolaritas = darah • Loop of Henle: • Descending limb  reabsorbsi 15% air • Thick ascending limb  impermeable thd. air • Reabsorbsi HCO3- (10-20%) • Sistem Na+ -K+ -2Cl- symport: • Reabsorbsi Na+ & Cl- (35%) • K+ kembali ke tubulus • Reabsorbsi kation: Na+, K+,Ca2+ (20-30%), Mg2+ • Akhir loop of Henle: osmolaritas

  24. http://www.mscd.edu/~biology/2320course/2320images/nephron.jpghttp://www.mscd.edu/~biology/2320course/2320images/nephron.jpg

  25. Reabsorbsi di Tubulus Distalis • Sistem Na+ -Cl- symport • Hormon parathyroid  reabsorbsi Ca2+ • Reabsorbsi air 10-15% • Akhir tubulus distalis: 90-95% ion & air terserap http://www.varimed.hu/hypertension/pha/img/pha_577.gif

  26. Reabsorbsi & Sekresi di Ductus Collectivus Principal cells: reabsorbsi Na+ & sekresi K+ • Intercalated cells: reabsorbsi K+ & HCO3- ; sekresi H+ http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/N/nephron.gif

  27. Regulasi Reabsorbsi & Sekresi oleh Hormon • Sistem Renin – Angiotensin – Aldosteron • Vol darah  sel juxtaglomerular renin angiotensin converting enzyme angiotensinogen  angiotensin I  angiotensin II • Angiotensin ll: • Vasokonstriksi arteriola afferent  GFR • Reabsorbsi Na+, Cl- , dan air di tubulus proximalis • Stimulasi kortex adrenal  aldosteron  reabsorbsi Na+, Cl- dan sekresi K+ di ductus collectivus  reabsorbsi air

  28. Hormon Antidiuretik (ADH)/ Vasopressin • Reabsorbsi air di bagian akhir tubulus distalis & • ductus collectivus (urine = 400 – 500 mL) • Osmolaritas plasma  osmoreseptor • hipothalamus  hipophysis  ADH  tubulus • distalis & ductus collectivus • Atrial Natriuretic Peptide (ANP) • Volume darah  ANP dari jantung • Inhibisi reabsorbsi Na & air di tubulus proximal & ductus collectivus • Inhibisi sekresi aldosteron & ADH

  29. Karakteristik Urine Normal • Volume: 1 – 2 liter per hari • Warna: Kuning atau kuning sawo/ kuning gading (amber), karena urokrom (hasil pemecahan pigmen empedu) dan urobilin (hasil pemecahan hemoglobin). Urin pekat berwarna gelap. Diet (misal: bit merah), obat, penyakit, berpengaruh pada warna. Batu ginjal  darah • Turbiditas: transparan (urine baru); berkabut (dibiarkan) • Bau: aromatik ringan (baru)  amonia (dibiarkan); metilmerkaptan (pada orang tertentu yang makan asparagus ); bau buah (badan keton pada diabetes mellitus)

  30. pH: antara 4,6 – 8,0 (rata-rata 6,0). Diet tinggi protein  asam; diet tinggi sayuran  basa • Berat jenis: antara 1,001 – 1,035. Konsentrasi zat terlarut meningkat  BJ meningkat

  31. Diuresis • Memperlambat reabsorbsi air • Terapi hipertensi • Diuretik alami: kopi, teh, soda (inhibisi reabsorbsi Na+), alkohol (inhibisi ADH) • Mekanisme kerja kebanyakan diuretik: inhibisi reabsorbsi Na+ • Furosemide (Lasix)  inhibisi Na+ K+ 2 Cl- symporters di thick ascending limb of the loop of Henle • Chlorthiazide (Diuril)  tubulus distalis (inhibisi Na+ Cl- symporters)

  32. Evaluasi Fungsi Ginjal • Urinalisis • Tes darah • Blood Urea Nitrogen (BUN) • Katabolisme asam amino  urea  nitrogen • GFR  BUN • Kreatinin plasma • Katabolisme fosfat kreatinin dari otot skelet • Fungsi ginjal  Kreatinin darah • Renal plasma clearance: volume darah yang dibersihkan dari substansi tertentu per unit per waktu (mL/ menit) • Renal plasma clearance substansi C = U X V P

  33. Transportasi, Penyimpanan, dan Eliminasi Urine • Urine duktus kolektivus = urine vesica urinaria • Ureter (peristaltik) • Vesica Urinaria • Vesicoureteral reflux • Ureterorenal reflex (konstriksi a. afferen) • Refleks micturitio • Urethra • Inkontinensia urine http://hcd2.bupa.co.uk/images/factsheets/kidney_stones.gif

  34. Inervasi: • Parasimpatis (S2 – S3  nervus pelvicus  plexus sacralis); sensoris & motoris • Simpatis (L2  nervus hypogastricus): pembuluh darah • Somatis (nervus pudendus  m. sphincter externus) http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_McKinley/f27-9a_urinary_bladder_c.jpg

  35. http://images.google.co.id/imgres?imgurl=http://clem.mscd.edu/~raoa/bio2320/uriphys/img038.jpg&imgrefurl=http://clem.mscd.edu/~raoa/bio2320/uriphys/sld038.htm&h=539&w=719&sz=43&hl=id&start=1&tbnid=RIxPxSlvLPYN0M:&tbnh=105&tbnw=140&prev=/images%3Fq%3Dmicturition%2Breflex%26svnum%3D10%26hl%3Did%26lr%3D%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://clem.mscd.edu/~raoa/bio2320/uriphys/img038.jpg&imgrefurl=http://clem.mscd.edu/~raoa/bio2320/uriphys/sld038.htm&h=539&w=719&sz=43&hl=id&start=1&tbnid=RIxPxSlvLPYN0M:&tbnh=105&tbnw=140&prev=/images%3Fq%3Dmicturition%2Breflex%26svnum%3D10%26hl%3Did%26lr%3D%26sa%3DG

  36. Pengisian Vesica Urinaria • Vesica Urinaria kosong  Tekanan = 0 cm air • Urine 30 – 50 ml  Tekanan tonik naik 5 – 10 cm air • Urine 200 – 300 ml  Tekanan naik sedikit (micturition reflex) • Urine 300 – 400 ml  Tekanan naik cepat

  37. Tekanan tonik meningkat • Kontraksi mikturisio: reseptor sensoris regang  • stretch reflex  nervus pelvicus  kontraksi m. • detrusor (bbrp detik – 1 menit; semakin penuh • semakin sering) • “Self regenerative” micturition reflex • Urine tidak dikeluarkan  inhibisi bbrp menit – 1 • jam • Refleks mikturisio meningkat  refleks inhibisi via • n. pudendus  m. sphincter externus

  38. Fasilitasi & Inhibisi Mikturisio oleh Otak • Pusat-pusat fasilitasi & inhibisi di batang otak terutama pons • Pusat-pusat di korteks serebri, terutama inhibisi tapi dapat menjadi eksitatoris • Pengaturan miksi oleh otak/ pusat-pusat atas: • Inhibisi parsial • Mencegah mikturisio via kontraksi tonik m. sphincter externus • Fasilitasi pusat mikturisio sakral  refleks mikturisio & inhibisi m. sphincter externus • Urinasi sadar  kontraksi abdomen

  39. Abnormalitas mikturisio • Destruksi serabut saraf sensoris  hilang kontrol  overflow incontinence (tabes dorsalis pada syphilis  radiks dorsalis) • Kerusakan spinal di atas regio sacral • “spinal shock” kemudian refleks kembali • Kerusakan parsial medula spinalis/ batang otak • Sinyal inhibitoris hilang • Impuls fasilitasi tak terkontrol  urinasi sering, tak terkontrol

  40. Pembentukan Urine Encer & Pekat • Total volume cairan tubuh konstan • Homeostasis: Ginjal memproduksi urine encer/ pekat • ADH mengontrol kepekatan urine

  41. Pembentukan Urine Encer • Osmolaritas cairan interstisiil  osmolaritas cairan tubuler • Symporters Na+, K+, Cl- pada thick ascending limb dari loop of Henle • Thick ascending limb tak permeable terhadap air  150 mOsm/l di akhir loop of Henle • Tubulus kontortus distalis tak terlalu permeable terhadap air & tak diregulasi oleh ADH • Kadar ADH rendah, duktus kolektivus tak permeable terhadap air  65 – 70 mOsm/l

  42. Pembentukan Urine Pekat • Asupan air sedikit/ kehilangan air banyak • ADH  urine pekat (4x), 1200 mOsm/l • Gradien osmotik cairan interstisial (Na+, Cl-, urea) • Perbedaan permeabilitas dan reabsorbsi air & zat terlarut di loop of Henle panjang (nephron juxtaglomerular) & duktus kolektivus • Countercurrent flow

  43. Proses Produksi Urine Pekat • Symporters di thick ascending limb (Na+, K+, Cl-)  gradien osmotik di medula renalis. Air tak direabsorbsi • Duktus kolektivus menyerap air (karena ADH) • Duktus kolektivus di medula bagian dalam menyerap urea (karena difusi & permeable terhadap urea)  akumulasi di jaringan interstisial • Difusi urea ke descending & thin ascending limb of Henle • Urea tetap di lumen thick ascending limb, tubulus distalis, duktus kolektivus kortikal (karena tak permeable terhadap urea  siklus 2 – 4 berulang (daur ulang urea)

  44. Countercurrent Mechanism • Osmolaritas cairan interstisial meningkat dari 300 mOsm/l (korteks renalis)  1200 mOsm/l (medula renalis) • Arah aliran descending limb >< ascending limb of Henle • Descending limb: Air keluar via osmosis; tak permeable terhadap zat terlarut kecuali urea  osmolaritas tubular (1200 mOsm/l) • Ascending limb: Na+, Cl- symporters; tak permeable terhadap air; osmolaritas tubular (100 mOsm/ l)

  45. Vasa recta • Osmolaritas awal masuk vasa recta = 300 mOsm/l • Osmolaritas mengikuti loop of Henle • Descending limb: Na+, Cl- masuk (cairan interstisial •  vasa recta) • Ascending limb: Na+, Cl-, urea, keluar (vasa recta •  cairan interstisial); air masuk (cairan interstisial •  vasa recta) • Osmolaritas akhir vasa recta = 320 mOsm/l

  46. Rujukan • Tortora GJ & Derrickson B, 2006. Principles of Anatomy and Physiology, 11th ed, John Wiley & Sons, Inc, pp 992 – 1035 • Guyton AC & Hall JE, 2006. Textbook of Medical Physiology, 11th ed, Elsevier Inc, pp. 311 - 314

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