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Urinary System Diseases. Pathophysiology. Review of Urinary Anatomy & Physiology. Located: Under back muscles Behind peritoneum Thus: retroperitoneal Below level of lowest ribs Right lower than left Adrenal gland on top of kidney Cortex Medulla Contains Pyramids & Papilla Pelvis

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Urinary system diseases

Urinary System Diseases

Pathophysiology


Review of urinary anatomy physiology
Review of Urinary Anatomy & Physiology

  • Located:

    • Under back muscles

    • Behind peritoneum

      • Thus: retroperitoneal

    • Below level of lowest ribs

    • Right lower than left

    • Adrenal gland on top of kidney

  • Cortex

  • Medulla

    • Contains Pyramids & Papilla

  • Pelvis

    • Calyx = division of pelvis

      • Pleural = calyces


  • Bladder

    • Lined with transitional epithelium

      • Can stretch

    • Lined with rugae

    • Trigone

      • On posterior wall

      • Where ureters & urethra open

      • Rigid area with NO rugae

    • Micturition (voiding, urination)

      • Internal urinarysphincter

        • Involuntary

      • External urinary sphincter

        • Voluntary

      • Stretch receptors in bladder wall


  • Nephron = functional unit

    • Consists of:

      • Renal Corpuscle

      • Renal Tubules

  • Renal Corpuscle contains:

    • Bowman’s capsule

      • Part of collecting system

    • Glomerulus

      • Afferent arteriole

      • Efferent arteriole

  • Renal Tubules

    1. Proximal convoluted tubule

    2. Loop of Henle

    3. Distal convoluted tubule

    4. Collecting tubule


Key point:

The cortex contains all the structures of the nephron

The medulla contains only the collecting ducts & the loop of Henle


Functions of the kidney

Removes nitrogenous wastes

Urea

Uric acid

Creatinine

Ammonia

Maintains homeostasis

Fluid balance

Electrolyte balance

Acid-base balance

Excretory Organ

Via blood filtration & formation of urine

Regulation of Blood Pressure

Juxtaglomerular apparatus

RAA system

Renin

Angiotensin

Aldosterone

Urine formation

Filtration

Occurs in renal corpuscle

Reabsorption

Occurs in proximal convoluted tubule

Also occurs in distal convoluted tubule

It takes things back into blood

Secretion

Occurs in distal convoluted tubule

Blood gives things up to the urine

Concentration

Occurs in collecting tubules

See next slide


Some key points of renal physiology
Some Key Points of Renal Physiology

  • Nitrogenous wastes primarily come from breakdown of proteins

  • Aging & renal function

    • By age 35, one begins to lose nephrons

    • By age 80, one has approx. 30% reduction in nephron capacity

  • GFR = glomerular filtration rate

    • Normal = 125cc/min (7500cc/hour)

    • 99% of filtered product is reabsorbed

      • Normal urine output = 60cc/hour (1500cc/day)

  • All along the duct system water is reabsorbed

    • Includes the prox. conv. tubule, loop of Henle, distal conv. Tubule, & collecting tubule

    • Sodium follows water

  • Key elements involved in each process

    • Reabsorption = H2O(Na), proteins (amino acids), & sugars(glucose)

    • Secretion = ions(K+), drugs, ammonia

    • Concentration = more reabsorption of H2O



    • Unique arrangment of blood vessels

      • Afferent arteriole -----to----capillary bed-----to----efferent arteriole -----to-----capillary bed ----to---- veins

        • First capillary bed = glomerular capillaries

        • Second capillary bed = peritubular capillaries

    • Purpose of this = to control the pressure in the glomerular capillaries & consequently the glomerular filtration pressure

    • 3 factors control this:

      • (1) autoregulation

        • Local feedback from muscle tension in afferent arteriole

        • Local feedback from DCT at JGA

        • Mediated via endothelial

        • secretions of glomerular capillaries

      • (2) sympathetic nervous system

      • (3) renin

    Volume of urine also controlled by glomerular filtration rate



    • Hormones failure help control the volume of urine via fluid & electrolyte balance

      • The concentration factor essentially deals with urine volume

        • Usually more the volume = more the dilution [a direct proportion]

          1. Aldosterone

          • From adrenal cortex

          • Works on distal convoluted tubule

          • Causes H2O & Na+ retention

            2. Atrial natriuretic hormone(ANH)

          • From atrial wall of heart

          • Works on distal convoluted tubule

          • Works in opposition to aldosterone

          • Causes H2O & Na+ loss

            3. Antidiuretic hormone

          • From posterior pituitary

          • Works on collecting tubules

          • Causes reabsorption of H2O (Na+ goes with it)


    Diagnostic tests urinalysis

    1 failure. Physical Characteristics &Measurements

    appearance

    color

    odor

    volume

    specific gravity

    2. Chemical Measurements

    pH

    protein; glucose

    ketones

    bilirubin; urobilinogen

    leukocytes; nitrite

    blood

    3. Microscopic

    cells (wbc, rbc, sperm)

    casts

    crystals

    bacteria

    4. Detection of Bacteriuria

    nitrite test

    qualitative or screening test

    C & S

    Colony Count, if done, make this a quantitative test

    NOTE: Step 4, qualitatively, is doneas part of step 2

    Diagnostic Tests - Urinalysis


    Appearance failure

    Clear = normal

    Cloudy = ? Infection

    If sediment = kidney disease

    Dark = ?blood, ?bilirubin, ?concentrated

    Color

    Urochrome pigment = yellow

    comes from breakdown of hemoglobin

    Concentration

    More Concentrated = Deeper Yellow

    Change of Color From:

    Meds

    Vitamin = yellow

    Diseases

    Blood = red-brown

    Liver = Orange

    Foods

    Rhubarb = red-brown

    Odor

    Normal = ammonia-like smell

    from breakdown of urea

    Unpleasant = ? infection

    Quantity

    Average per 24 hours = 1500 cc

    60 cc per hour

    GFR = 125 cc/min

    Thus, 7500 cc/ hour

    Urine Made Per Hour = 60 cc

    Urine GFR Per Hour = 7500 cc

    KEY: 1 % of filteredurineremains urine; 99 % becomes reabsorbed back into blood

    Oliguria = 100 - 400 cc per day

    Anuria = less than 100 cc per day

    Polyuria = diabetes, nerves, diuretics


    Specific Gravity failure

    Determines Concentration

    Compares Test Liquid to H2O

    Normal = 1010 - 1030

    First AM Specimen = > 1020

    In many kidney diseases, one loses the ability to concentrate urine

    3 ways to do it:

    1. Reagent Strip

    2. Refractometer

    3. Urinometer

    pH

    Determines Acidity or Alkalinity

    Normal = 6.0

    Range = 4.5 - 8.0

    Acidity example = diabetes

    Alkaline example = UTI

    Protein

    OK to have a Trace in the urine

    Benign Conditions:

    exercise

    exposure to cold

     protein consumption

    Generally Means Kidney Disease

    Glucose

    Will only be in urine if exceed Renal Threshold (160 - 180 mg/dl)

    Ketone (note Acetone is a Ketone)

    Ketones are products of Fat Metabolism

    If cant breakdown Sugars for energy, the body will begin using Fat

    Seen in:

    Uncontrolled Diabetes

    Starvation

    Hi-Fat Diet


    Bilirubin & Urobilinogen Formation failure

    When used-up RBC’s are broken down by R-E System, a by-product is Bilirubin

    Bilirubin removed from blood by liver & excreted into intestine

    Bacteria in intestine convert Bilirubin into Urobilinogen

    Some Urobilinogen reabsorbed into blood

    Of this amount reabsorbed some my be normally passed in urine

    Bilirubin

    Normally None in Urine

    Found in urine if it can’t get from the liver into G-I tract

    From Obstruction of Bile Ducts

    Found in urine if have:

    Liver Disease (hepatitis)

    Blood Disease (hemolysis)

    Urobilinogen

    generally follows whatever happens to bilirubin

    may get none in urine if on antibiotics (destruction of gut flora)

    usually get small amount in urine

    Blood

    None is normal

    But may see some if female is menstruating

    Leukocytes

    from inflammation of kidney or lower G-U tract

    Nitrites

    screening test for bacteriuria

    bacteria convert nitrate to nitrite


    Other diagnostic tests
    Other Diagnostic Tests failure

    • Blood tests

      • BUN / creatinine

      • CBC ------ anemia if decreased EPO production

      • Renin

      • Antistreptolysin titers

  • Urine culture & sensitivity (C&S)

    • Include colony count

  • Imaging

    • IVP

    • Retrograde pyelography

    • CAT/ MRI

  • Surgical procedures

    • Cystoscopy

    • Biopsy


  • Urinary tract disorders overall outline
    Urinary Tract Disorders failureoverall outline

    • Incontinence & retention

    • UTI’s

    • Inflammatory disorders

    • Nephrotic syndrome

    • Urinary tract obstruction

      • Stones

      • Hydronephrosis

      • Tumors

        • Renal cell carcinoma

        • Bladder cancer

  • Congenital disorders

    • Polycystic kidneys

    • Wilm’s tumor (nephroblastoma)

  • Renal failure

    • Acute

    • Chronic

    • Dialysis


  • Incontinence retention catheters

    Urinary Incontinence failure

    Loss of voluntary control of bladder

    Frequently called “neurogenic bladder”

    Many causes

    Enuresis = involuntary control after age 4 or 5

    Types:

    Stress

    Urge

    Overflow

    Urinary retention

    Called “residual urine”

    Causes :

    Anatomical defects

    Neurogenic defects

    Treated with “catheterization”

    Foley

    French

    Incontinence, retention, & catheters


    Urinary Tract Infections failure

    Urethritis; Cystitis; Pyelonephritis

    • Etiology

      • Ascending infection ----- women > men

      • Prostatic hypertrophy with urinary retention

      • Incomplete emptying of bladder with urinary stasis

      • Pregnancy associated with stasis

      • Blood borne pathogens

    • Pathophysiology of UTI’s ----- see next slide

    • Dx

      • Dysuria, urgency, & nocturia

      • Systemically get fever & malaise

      • CVA tenderness in pyelonephritis

  • Note glomerulonephritis is vastly different with regards etiology & pathophysiology


    • Note etiologies failure

      • Inflammation of mucosa

      • Trauma of mucosa

      • Obstruction

      • Vesicoureteral reflux

      • Immobility

      • Blood-borne pathogens

        • TB

        • HIV

        • Septicemia


    Inflammatory disorders 1 glomerulonephritis 2 nephrotic syndrome

    Glomerulonephritis failure

    Acute

    Sx = proteinuria, edema, oliguria

    Etiol = 1-2 weeks post strept infect.

    Chronic

    Etiol = autoimmune disease

    e.g. lupus, diabetes, hepatitis C

    Can lead to irreversible kidney damage

    Inflammatory disorders(1) glomerulonephritis (2) nephrotic syndrome


    • Nephrotic Syndrome failure

      • Glomerular disorder where one loses the capacity to retain protein, especially albumin

      • Sx

        • severe edema (anasarca)

        • * can get skin breakdown since impaired arterial flow

        • proteinuria

        • hypoalbuminemia

        • oliguria

      • Etiol:

        • Toxic agents (lead, mercury)

        • Toxic drugs (aminoglycosides)

        • Diseases (diabetes, lupus

      • Key = any significant problem with

      • glomerulus can lead

      • to nephrotic syndrome


    Obstructive disorders

    Tumors failure

    Note that primary symptom = hematuria

    Renal Cell Ca = most common, unilateral, adeno Ca from tubular epithelium

    See picture

    Bladder Ca = usually from transitional epithelium

    Neurogenic bladder

    Renal Calculi

    Etiology: Calcium, Uric acid, Urine crystals

    Symptoms: renal colic, N&V, chills, fever

    Risk factors: prolong dehydration, prolong immobilization, infection

    Treatment: surgery,lithotripsy

    Anomalies

    Strictures

    Kinks

    Ptosis

    Pelvic kidney

    Obstructive Disorders


    • These result in: failure

      • Hydronephrosis

      • Hydroureter

    • If these conditions exist longer than 2 months get destruction of kidney

    Major sites of urinary tract obstruction


    • Congenital Diseases failure

    • Vesicoureteral reflux

      • Due to ectopic insertion of ureter into bladder. If far away from trigone, do not get adequate compression of ureter when voiding & get reflux

      • Incidence: 1/1000

      • If one gets it each sibling(to be) has 50% incidence

      • Girls> boys; 10:1 ratio

  • Ectopic kidney

    • May get kinking of ureter

    • Usually in pelvis

    • Asymptomatic

  • Renal agenesis

    • Usually unilateral & left kidney

    • 2 types: (1) occurs randomly (2) genetic

    • Asymptomatic

    • Remaining kidney becomes large since compensatory hypertrophy


  • Congenital Diseases failure(cont)

    • Polycystic kidney (2 types

      • In adults (see picture)

        • Genetic etiol ----- autosomal dominant

        • Clinically seen in adults

          • Between age 30 – 40 one begins to get renal failure

        • Tx = transplant

      • In children

        • Genetic etiol --- autosomal recessive

        • Manifest at birth; usually fatal or infant stillborn

        • Rare

    • Wilm’s tumor (nephroblastoma)

      • Most common tumor of children; usually unilateral

      • Etiol = autosomal recessive (on chromosome 11)

      • Manifests between age 2 – 5 years & presents as abdominal mass

        • May produce hypertension

      • 5 year survival = 90%


    Renal failure

    Acute renal failure failure

    Abrupt decrease in renal function

    Nitrogenous wastes accumulate

    Usually reversible

    Sx:

    Oliguria

    Drowsiness

    Altered levels of consciousness

    Etiol:

    Glomerular disease

    Severe pyelonephritis

    Nephrotoxins that damages tubular epithelium

    Ischemic causes

    shock

    ATN (acute tubular necrosis)

    e.g. burns(hgb accumulates)

    e.g. trauma (myoglobin accumulates)

    Renal Failure


    • Chronic Renal Failure failure

      • Get slow progressive loss of neurons

      • Usually irreversible

      • Course = gradual

      • Etiol:

        • Vascular disease

          • e.g. hypertension

          • Disease callednephrosclerosis

        • Glomerular disease

          • e.g. diabetes

        • Tubular disease

          • e.g. toxins

    Hypertension & the kidneys


    Dialysis in renal failure

    2 types: failure

    Hemodialysis

    Peritoneal dialysis

    Mechanism

    Simple diffusion for wastes & electrolytes

    Osmosis for water balance

    Dialysis in renal failure


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