The kidney

For this lecture please guys make sure that you read every single word in the slides Ok in this lecture we are going to talk about some of the disorders that happened in the renal system but before , lets review the physiology of the renal system ( kidneys ) . SO lets start:

-Urine Formation by the Kidneys: Glomerular Filtration, Renal Blood Flow, and Their Control

Functions of the kidneys : 1-excretion of metabolic waste products :

Urea (from protein metabolism) Uric acid (from nucleic acid metabolism) Creatinine (from muscle metabolism) Bilirubin (from hemoglobin metabolism) these are some of the parameters to check the wellness of the kidneys (Kidney function tests ) these are common lab tests used to evaluate how well the kidneys are working. Accumulation of these waste products ( urea, uric acid , creatinine and bilirubin ) reflects abnormality in the kidneys .

2- Excretion of foreign chemicals:

a-Food additives b-Toxins c-Pesticides d-Drugs

3- secretion , metabolism & excretion of hormones: Hormones produced in the kidney:

a- Renal erythropoietic factor : involved in the Erythropoiesis process ( production of the RBCs ) by enhancing the production of the RBCs from the bone marrow due to hypoxia SO it produced as a result of Hypoxia => which will stimulate the release of Retropeotein as to enhance new RBCs formation

b-Renin :involved in the coversion of angitensin 1 to angiotensin 2 then converted into angiotensin 2 by ACE (Angiotensin-converting enzyme ) . c- 1,25 dihydroxycholecalciferol ( calcitriol )=( the hormonally active form of vitamin D) . Hormones are metabolized and excreted by the kidneys : Most peptide hormones (e.g:insulin, angiotensin II, etc.)

3- Regulation of erythrocytes production :

4- Regulation of vitamin D activity : Kidney produces active form of vitamin D (1,25 dihydroxy vitamin D3 ) Vitamin D3 is important in calcium and phosphate metabolism

5- Gluconeogenesis ( synthesis of Glucose ): Gluconeogenesis: kidneys synthesize glucose from precursors (e.g., amino acids) during prolonged fasting \ starvation . 6- Regulation of acid-base balance :
-Excretion acids ( kidneys are the only means of excreting non-volatile acids ) -Regulation body fluid buffers (e.g. bicarbonate )

7- Regulation of arterial pressure:

 Endocrine Organ renin-angiotensin system prostaglandins kallikrein-kinin system Control of Extracellular Fluid Volume.

8- Regulation of water and electrolytes balances: Sodium and Water Potassium Hydrogen Ions

Calcium, Phosphate, Magnesium

SO to sum up here are the main functions of the kidneys : Excretion of metabolic waste products: urea, creatinine, bilirubin, hydrogen Excretion of foreign chemicals: drugs, toxins, pesticides, food additives Secretion, metabolism, and excretion of hormones - renal erythropoetic factor - 1,25 dihydroxycholecalciferol (Vitamin D) - Renin Regulation of acid-base balance Gluconeogenesis: glucose synthesis from amino acids Control of arterial pressure Regulation of water & electrolyte excretion

 And these functions are acomplished by a sereis of processes like : Filtration .. reabsorption . Secretion . Excertion of urine .
About 180 L of blood are filtered through the kidneys daily , 178.5 L are reabsorbed and 1.5 L are excreted as urine. so most of the filtered fluid is reabsorbed again .

the reabsorption process is important because we have 3L of plazma in our bodies which is filtered 60 times aday so without this process all the plazma will be gone with the urine . the kidneys get its arterial supply by the renal artery which is a branch of the abdominal aorta. The functional unit of the kidney is the Nephron which is composed of Bowman's capsule , proximal tubule, loop of Henle ( ascending and descending) , distal tubule & collecting duct . in Bowman's capsule there's a network of capillaries (all from the afferent branch of renal artery) From the other side of the capillaries of the glomerulus there is the efferent arteriole and from the efferent arteriole we get the Peritubular capillaries which are involved in the processes reabsorption and secretion ( PS: the reabsorption and the secretion happened between the pretubular capillaries and the tubules ..Filtration occurs between the glomerulus and Bowman's capsule )

We have 3 layers glomerulus ( a network of capillaries ) : 1-Epithelium of the glomerulus 2-Basement membrane 3-Endothelium (Wall of bowman's capsule) . the filtrate should cross these three layers .

20% of the blood that enters the kidney by the afferent arteriole is filtered the rest of the blood continue to the efferent arteriole then at the pretubular capillaries there will be either reabsorption of the materials that the body needs (like amino acids , electrolytes , water ..) or secretion .

SO :

Filtration: somewhat variable, not selective (except for proteins), averages 20% of renal plasma flow Proteinsare not filtered Because: 1- they have high molecular weight (large in size) 2- they are negatively charged and the basement membrane of theBowman's capsule is also negative . ( so there will be a repel between the basement membrane and the proteins ) In some cases we might have some proteins with low M.W but It's amount in urine shouldn't be higher than 150 mg daily. - The presence of proteins in urine (known as Proteinuria) indicates that we have a problem in the kidney. Its occures between the glomerulus and the bowmans capsule . -

Reabsorption: highly variable and selective, most electrolytes (e.g. Na+, K+, Cl-) and nutritional substances (e.g. glucose) are almost completely reabsorbed; most waste products (e.g. urea) poorly reabsorbed Secretion: variable; important for rapidly excreting some waste products (e.g. H+), foreign substances (including drugs), and toxins.

Renal Handling of Water and Solutes :

Filtration Water (liters/day)

Sodium (mmol/day)
Glucose (gm/day) Creatinine (gm/day)

180 25560 180 1.8

Reabsorption 179 25410 180 o

Excretion 1 150 0 1.8

Notioce here that the glucose is fully reabsorbed . if we fined glucose in the urine ( excertion for glucose was more than 0 ) this means that we have glucose urea or hyperglycemisa which happens in diapetas maletus .

NOW lets start the Pathophysiology of the renal system

1-Disorders of urine volume :

Normally urine volume/24 hours ~ 1-1.5 liter And these disorders are : Anuria: (no urine excretion) is due to either a. Total urinary obstruction. b. Vascular occlusion. Oliguria - urine output < 500 ml per day Polyuria :- urine output > 3 liters per day

Caused by : -Excess fluid intake -Hyperglycemia -Diabetes inspidus (decreased or absence of antidiuretic hormone) -Drugs diuretics -Toxins lithium.
The minimum amount of urine shouldn't be < 500 ml Because the metabolic waste products can't be excreted in a dry form so they must be diluted, and the minimal amount of fluid needed to get them diluted is 500 ml .

2-Hematuria
Hematuria is the presence of blood in urine

Hematuria might be:

Frank : seen by the naked eye , the blood is seen on the urine ( red urine ) Microscopical: blood or RBCs are only seen by microscope .

Hematuria reflects ( causes if Hematuria ):

A.Kidneys:
a- Clotting disorders b. Cyst c. Tumor d. Glomerular disease e. Interstitial disease f. Infarction

B. Ureter:
a. Cancer

b. Stone

C. Urinary Bladder Infection: D. Urethra: Trauma in urethra

It's extremely rare to find a benign hematuria \ without cause (reflects no presence of a pathological situation ) Normally Few RBCs are detected by microscope. Dipstick test can detect microscopical bleeding. Dipstick test is positive during

Examination of urine is helpful in establishing the cause of hematuria menstruation:.

Presence of WBCs and micro-organisms suggests infection, so the presence of WBCs with the RBCs in urine reflects the presence of sever UTI(Urinary Tract Infection=immunological reaction)

Presence of RBC casts suggests glomerular bleeding

Causes of Hematuria :
Glomerular bleeding suggests fracture in the glomerular basement membrane GBM))
Glomerular bleeding may develop after strenuous exercise, ( Heavy exercise may lead to hematuria)

Recurrent episodes of gross hematuria associated with respiratory tract infection indicates IgA nephropathy

 Glomerulonephritis with deposition of IgA in mesangial cell Red urine due to haematuria must be differentiated from other causes of red or black Urine. Red urine can sometimes be due to other reasons like food dye or drugs (e.g. Rifampicin gives the urine orange color )and during menstruation there might be some RBCs in the urine but they are from the vagina not the renal system.

3- Proteinuria
The presence of abnormal concentration of Proteins in urine . Apperes in hypertention and diapetus maletuas Proteinuria is as important as the hematuria because it also indicates that there is a problem in the urinary tract It makes the urine froth easily ( soupy )

Normally low molecular weight proteins are filtered at the glomeruli but they are reabsorbed(by the tubular cells ) because the body needs them, Appearance of more than 150mg of low molecular weight proteins in the urine means failure of the reabsorption by the tubular cells and indicates tubular cell damage .

Proteinuria of low molecular weight proteins more than 2g/day indicates significant glomerulus disease.

Albuminuria Normally albumin ( has a high M.W ) is not filtered at glomeruli .Presence of albumin in the urine is a positive sign of glomerulus disease Albuminuria is seen in early stages of glomerular disease of diabetes mellitus "diabetic nephropathy " also in hypertension. Minor leakage of albumin into glomerular filtrate may occur temporarily after vigorous exercise fever and heart disease.

Forgive us for any mistake ,,,, and really sorry if it took us so longed to finish it ,,, bas ento 3arfeen 3aj8et el2mte7anat :P wish you guys all the best in the exam ,,,, study well and GOOD LUCK <3 Rmz Rabadi & Gayda2 Ken3an