Renal Function

1) Review
a) Filters plasma at the glomerulus to produce a protein free
ultrafiltrate
i) 125 ml/min (18 L/day)
ii) kidneys filter blood
iii) glomerulus looks like fist punch into balloon
iv) ultrafiltrate filters so many substances.
v) someone with normally fnxng kidneys normally has
concentrated urine
b) Reabsorbs 99% of filtered fluid in renal system
c) Secretes selected substances
d) Regulates ionic composition and tonicity of body by regulating
rate of absorption and secretion
e) Disposes of waste by filtration and secretion
2) Gross Anatomy (review or nephrons)
a) Renal artery branches from abdominal aorta and there are many
sub levels of intrarenal arteries
b) Afferent (in) and Efferent (exit=out) Arterioles go in and out of
glomerulus
c) Renal Cortex-contains 85% of all nephrons (why we wear kidney
pads in football)
d) Renal Medulla- contains renal pyramids and columns, where the
nephrons in this area concentrate the urine
e) Renal Pelvis the expanded proximal end of the ureters (2) (1
urethra)
f) Ureters- drain urine into the bladder
3) Typical Kidney Placement

4)

5) Structures of the Kidney

6) Structures of the Kidney

7) Nephron Anatomy
a) Glomerulus tuft of capillaries where filtration occurs
b) Proximal Convoluted Tubule branches from Bowmans capsule
where 2/3 of electrolytes are reabsorbed, also, all glucose, all
amino acids are reabsorbed
c) if see glucose or amino acids in urine, somethings wrong with
the CT
d) Loop of Henle descending and ascending loops of the renal

tubule, reabsorbs Na, K, Cl

e) Distal Convoluted Tubule - reabsorbs Na, Cl, reabsorbs or
secretes K, is hormonally controlled (ADH)
f) Collecting Duct- Tubules that receive urine from several renal
tubules eventually direct urine to the pelvis of the kidney

8) Transport Functions of Nephron

a) Glucose reabsorption
i) proximal tubule, has maximum, Na-dependent
b) Acid Base Balance
i) secretes H+, results in HCO3 reabsorption or can be buffered
by secreted buffers (NH3, HPO4)
c) Potassium
i) reabsorbed or secreted depending on need, secretion
regulated by aldosterone in distal tubule
d) H20
i) follows Na in PT, DT, independently regulated by ADH in
collecting tubule, gradient set up by loop
9) Nephron Function

10)

Structure of the Glomerulus

11) Filtration
a) Nephrons filter plasma at the glomerulus. Fluid is filtered from
glomerular capillary into Bowmans space
b) Glomerulus is freely permeable to water, but not large plasma
proteins (and glucose) when in a non-diseased state.
c) Molecule size and electrical charge affect permeability of
substances.
d) Fluid contains electrolytes and organic molecules such as
creatinine, urea, and glucose
12) Capillary Pressure
a) Affects glomerular filtration.
b) Hydrostatic pressure within capillary is major force for moving
water and solutes across the filtration membrane into Bowmans
capsule. Blood (hydrostatic) pressure is higher than BP in other
capillaries
c) Two forces oppose the filtration effects of this glomerular
capillary hydrostatic pressure
a) The hydrostatic pressure in Bowmans space pushing
against walls
b) The oncotic pressure of the glomerular capillary blood
pulling things towards it

13) Tubo/glomerular Feedback

a) Juxtaglomerular apparatus - specialized region where distal
tubule contacts afferent and efferent arteriole of its nephron
i) Synthesizes renin and act as baroreceptors monitoring bp
b) Feedback between the DT and the glomerular capillaries helps
maintain homeostasis of
(a) -GFR (glomerular filtration rate)
(b)-amount of urine produced
(c) -overall blood volume and electrolyte concentration
c) Macula densa
i) Sense plasma sodium concentration and pass the message to
the renin-secreting cells
ii) Are part of the thick ascending limb of the nephron
14) NaCl
a) the distal convoluted tubule controls GFR by changing diameter
of afferent and efferent arterioles. It can also change the
permeability of the glomerulus
i) increased NaCl in distal tubule decreases GFR
a) -whereever NA is it will hold fluid where its at.
ii) decreased NaCl in DT increases GFR
a) bc that ind is urinating more out. Wherever NA is, fluid
follows. NaCl is direct substance used at distal tubule ot
either maintain/get ride of fluid volume
b) there are many diuretics that target distal tubule or loop of
henle
15)
a)
b)
c)
d)

Transport Functions of the Nephron

Glucose transport
Acid Base Balance- secretion of H+, results in HCO3 reabsorption
Potassium- reabsorbed and secreted
H20- follows Na in PT & DT, is independently regulated by ADH in
collecting tubule, gradient set up by loop of Henle

16) Renal Hormones

a) Erythropoietin stimulates red blood cell proliferation/production
in bone marrow, stimulated by kidney (sensors that recognize
low levels of O2 in afferent mechanism) hypoxia (also available
as a recombinant protein given as SQ injection)
i) when person in state of kidney disease, will have alteration in
RBC count. Need to supplement exogenous injection of
erythropoietin for oflks in hemodialysis
b) Atrial natriuretic peptide- secreted from cardiocytes in the right
atruim when R atrial blood pressure increases. Inhibits sodium
absorption in the collecting duct, increasing urine formation, thus

decreasing blood volume and blood pressure

c) Hydroxylation (activation) of Vitamin D precursors -- what will
happen to Ca in renal failure? Without precurors, cant create vit
D after being exposed to sunlight. Without D, cant absorb
Calcium.
d) Inactive Vitamin D is synthesized by the action of ultraviolet
radiation on cholesterol in the skin (face and hands)
i) Since vitamin D is needed for the absorption of calcium, if
renal disease exists, calcium levels will adversely be affected.
17) Functional Tests
a) Urinalysis
b) BUN/Cr (blood urea nitrogen/ creatinine) need to take a sample
of someones blood.
i) Cr is a by product of muscle metabolism (in steady state
produced and lost at constant rate) Blood levels depend on
Glomerular Filtration Rate (rise as GFR decreases)
ii) dont want nitrogenous wastes circulating through blood
cause youll go cookoo.
c) Creatine Clearance a measure of GFR
d) Intravenous pyelograms (IVP) closer look. Insert radio-opaque
dye to visualize each kidney and how it uptakes dye or not
uptaking dye
i) pictures with radio-opaque dye
e) Ultrasound, CT, MRI
f) Biopsy
18) Polycystic Kidney Disease
a) Cysts develop in nephron - polycystic kidneys enlarged fluid filled
spaces
(a) either very young or older adult, cycst begin to grow in
nephron.
(b)Polycystic kidneys have very large fluid-filled spaces
(i) puts pressure on surrounding tissue and can cause
damage
b) Two types separated by genetic types that create them
i) autosomal recessive: seen in chidlren
ii) autosomal dominant: seen in adults
a) recessive manifests in children, dominant in adults 30 - 40
c) Sx: flank pain (assessed through phys exam), urinary tract
infections, hematuria leading to chronic renal failure
i) need of nephrons damaged to show any renal abnormality
19) Infection and Inflammation
a) Pyelonephritis pussie neprons. inflammation of the renal pelvis
i) acute - usually from a bladder infection. Backs its way up into

kidney. recover if treated

ii) chronic comes and goes. often from obstructive disorders;
leads to renal failure

b) Glomerulonephritis - inflammation of glomeruli

i) Acute - abrupt onset hematuria, proteinuria (proteins in urine)
with decreased Glmerular Filtration Rate (increased serum
BUN/Cr). often secondary to infection or immune process
(SLE, could be autoimune)
ii) Chronic comes and goes. hematuria, proteinuria with
progressive decline in GFR, often autoimmune
a) nephrons are super fragile
b) blindness is super common side effect of diabetes as
retinal cells also super fragile and neurons in periphery
also damaged easily in long-term uncontrolled diabetes
c) Kidney stones
i) Kidney Stones (renal calculi)
ii) Crystallized material (Most are calcium crystals) forms in renal
calyces and pelvis; sometimes descend thru ureters
iii) Cause not completely understood: decreased inhibitors in
urine? High concentrations of stone-forming substances? Gout
causes uric acid stones
iv) Occur symptomatically in 1% of population
v) Often recur
vi) VERY painful when they stretch ureter, obstruct flow. Shaped
with barbs. Bloody ureter. Urine gets backed up to kidney
system.
vii) Sx: severe pain in flank or groin, hematuria
a) Narcotic analgesia for acute attack
b) lithotripsy to break up stones (invasive snake the runs up
and pounds it down to sand)
c) Prevent new one from forming (dilute urine, dietary
changes)
20) Kidney stones get lodged
a) Minor and major calyces and in ureter
21) More Obstructive Disorders
a) Caused by
i) benign prostatic hyperplasia (prostate is growing and getting
too big that its almost obstructing the urethra. Not
cancerous.)
ii) early sx: cant write name in snow. Weakened flow.
iii) neuro or muscular problems (more rare)

iv) other causes (congenital: may need surgery)

b) Consequences:
i) depends on site of obstruction (think about physiology of
obstruction and know anything behind obstrucxn will have
prob)
ii) urine backs up: hydroureter (fluid fills in ureters, will be seen
on ultrasound or xray) or hydronephrosis (fluid in kidneys.
Cant funxn right)
iii) kidneys cant function
iv) infection common if chronic

22)

Urinary Tract Obstruction

23) Urinary Tract Infection

a) Usually bacterial, most commonly E.Coli and other GI inhabitants
(wiping from front to back in female gentilia)
b) Staphylococcus
c) How do the bacteria get into the urinary tract? sex
d) Who is most at risk of UTIs and why? Elderly women (wipe from
back to front) and sexually active owmen. Due to close

proximity.
e) Cystitis is Inflammation of the bladder (infection, irritation from
stones, trauma, chemical irritants)
f) Symptoms - frequency, urgency, dysuria (painful urination),
lower back pain, cloudy urine, hematuria, elderly may be
asymptomatic
g) Diagnsed by Urine Analysis /Culture
i) Bacterial infection- most common cause E coli bacterium
needs antibiotic
ii) Recurrent (< 6 months apart) are cause for more concern
24) Extensive Urinary Tract Infection
a) Pyelonephritis= infection has ascended to renal pelvis, much
more serious
i) all of cystitis symptoms, plus febrile
ii) acute onset of fever, chills, flank or groin pain (test for
costovertebral angle tenderness thru physical assessment)
iii) UA/culture
iv) often requires IV antibiotics
25) Nephrotic Syndrome
a) Increased permeability of the glomerular basement membrane to
protein
b) Collection of Symptoms simply defined with primary symptom
of proteinuria (>3.5 g/day).
c) Characteristic of glomerular injury.
d) Leads to hypoalbuminemia, hyperlipidemia, edema,
hypercoagulability, altered immunity, lipiduria (fat in urine) (all
these symptoms compound are why its called a syndrome)
26) Renal Failure
a) Decrease in renal function that is potentially reversible
b) Acute Renal Failure generally reversible
i) Classified by causes
a) Prerenal related to decreased renal blood flow
b) Post renal related to outflow obstruction
c) Intrarenal nephron damage
27) Chronic Renal Failure (need hemodialysis)
a) Progressive, predictable loss over months to years not
reversible
b) Final stage ESRD (End Stage Renal Disease)
28) Acute Renal Failure
a) Pre renal prevent by keeping well hydrated, maintain BP high

enough, give low dose dopamine to increase renal blood flow and
perfuse glomerulus
b) Acute tubular necrosis (damage to inside of nephron) an
intrarenal cause
i) Few cells actually die but may become non functional for a
while
ii) Tubule cells provide a poor barrier between filtrate and
interstitual space and filtered fluid leaks back into interstitum
iii) Recovery 2 weeks to up to 12 months (sometimes never
becomes chronic)
c) Post renal prevent or treat obstruction

29) Phases of Acute Renal Failure

a) Oliguric - urine output < 400 cc/day
b) Diuretic dilute urine (low specific gravity) in normal to > normal
amounts
c) Kidneys cant concentrate anymore. What goes in comes out
quick.
d) Recovery phase renal function adequate to avoid dialysis, but
not up to normal (renal insufficiency).
e) Cr increases, BUN increases in blood (azotemia)
f) When azotemia (and other waste products) causes symptoms =
uremia (fatigue, anorexia, N & V, pruritis [urine trying to excrete
through skin. Causes itchy. uremic frost], neurologic changes)
i) -Chronic condition when someone has higher concentration of
uric acid in blood
ii) -Put pt on dietary restricxn. Ie. Less protein so less
nitrogenous wastes.
30) Prevention/ Treatment of ARF
a) Increase renal blood flow with:
i) Diuretics such as furosemide (loop diuretics), mannitol
(osmotic diuretic. Pulls fluid out of vasculature and out of
body. Causes severe dehydration)
ii) Low dose dopamine
iii) Natriuretic peptide
iv) TEMPORARY DIALYSIS
31) Chronic Renal Failure
a) Causes 50% of folks with it, ESRD, is due to 2ndary to diabetes?

b) Stages
i) Decreased renal reserve Cr high end of normal no symptoms
ii) Renal insufficiency 75% of nephrons damaged, Cr, BUN
elevated but not much, polyuria, nocturia
iii) ESRD 90% of nephons destroyed hypervolemia,
hyperkalemia, hyperphosphatemia, metabolic acidosis,
uremia, hypocalcemia and osteodystrophy with osteoporosis
(due to non-ability to deal with Vit D), anemia
32) Prevention/ Treatment of ESRD
a) Tight glucose control in diabetics
i) Use hemoglobin A1C to test below limits
b) Dietary restrictions low protein, usually restrict PO4, K, Na (due
to fluid overload), supplement calcium, vitamin D
c) Transplantation (if young enough)
d) Dialysis (if not young enough for transplantation. No end to it.
Once start, its everyday. Go until done, when die quickly)

33) 2 Types of Dialysis

a) Hemodialysis AV shunt for access, blood pumped through array
of semipermeable membranes surrounded by dialysate
b) Peritoneal Dialysis dialysate placed into abdominal cavity
(peritoneum) and drained out by gravity flow, peritoneal
membrane acts as filter. Placed on this when cant handle
hemodialysis. Not long term. Dont wan to put in AV shunt if
dont have to. Uses peritoneal cavity as filter
34) Complications of ESRD/Dialysis
a) Osteodystrophy (defective bone development) stimulation of
Parathyroid Hormone by high PO4 circulation results in activation
of osteoclasts, Ca resorption (removal)
i) Eventually over time occurs.
b) Anemia loss of erythropoietin, hemodialysis causes RBC
damage, now use Epogen, Hematocrit ct in low 30 are routine
(adult usually in 40s)
c) Peripheral neuropathies
d) INFECTIONS vascular access or peritonitis. Over time risks
increase
e) Anorexia & weight loss diet restrictions + hypermetabolism
35) Review of Bladder
a) Sac for urine collection

i) Surrounded by smooth muscle under parasympathetic control

ii) Two ureters enter from kidneys, one urethra exits to outside,
urethra has internal sphincter
iii) External urethral sphincter is under voluntary control
36) Bladder Disorders
a) Bladder Cancer
i) more common in men,
ii) hematuria: irritable bladder type issue
b) Voiding Dysfunction (incl. urinary incontinence)
i) Common especially in women (20%)
37) 6 Types of Incontinence
a) Urge involuntary bladder contractions. Person at rest and then
all of a sudden, have to go. Its a spasm.
b) Stress weak pelvic muscle floor. Urethra and sphincter
weakened. Encourage kegel excersizes.
c) Mixed combination of urge and stress
d) Overflow dribbling. continuous escape of urine caused by
partial obstruction (prostatic hypertrophy)
e) Functional diagnosis when others fail. Dont really know reason
but its not psychiatric.
f) Reflex no sensory warning or awareness, neuro
38)
a)
b)
c)
d)
e)
f)
g)
h)

Treatments
Behavioral often nursing
Bladder training, pelvic muscle strengthening exercises (Kegel)
Pharmocologic
anticholinergic agent, estrogen
Devices
Urethreral plugs, Vaginal rings, Pads
Surgical
variety depending on problem