Homeostasis-2016 2017 ENG

EUROPOS SJUNGA
Europos Socialinis Fondas
Program of Medicine Studies
MODULE
HOMEOSTASIS AND EXCRETION

Second Year
Third Semester
Faculty of Medicine
Lithuanian University of Health Sciences
Contents
1. General information ...................................................................................................................... 5
2. General contents of the module .................................................................................................... 5
3. Aim and objectives of the module ................................................................................................ 6
4. Tutorials ......................................................................................................................................... 7
4.1. Case 1. Large kidney ................................................................................................................ 7
4.2. Case 2. Low weight of the baby ............................................................................................... 9
4.3. Case 3. Color of the urine like Coca-cola ........................................................................... 12
4.4. Case 4. Edema of the body. .................................................................................................... 16
4.5. Case 5. Blood in urine ............................................................................................................ 19
4.6. Case 6. Sweet urine ................................................................................................................ 22
5. Lectures ........................................................................................................................................ 25
5.1. Structure of the organs of the urinary system (2 hrs.) ............................................................ 25
5.2. Histophysiology of the organs of the urinary system (2 hrs.) ................................................ 25
5.3. Role of kidneys in homeostasis (2 hrs.) .................................................................................. 25
5.4. Regulation of water and electrolyte homeostasis with hormones (2 hrs.) .............................. 26
5.5. Disorders of renal functions. Changes in urine excretion and composition. Acute and chronic
renal failure, etiology, mechanisms of pathogenesis, disorders of body functions (2 hrs.) .......... 26
5.6. Structural principles of homeostasis and pathology of the organs of the urinary system (2
hrs.) ................................................................................................................................................ 26
5.7. Environmental factors, influencing homeostasis and renal function (2 hrs.) ......................... 27
5.8. Examination of the patients with diseases of the urinary system: interview, inspection,
palpation, percussion, auscultation. Laboratory and instrumental diagnosis. Main clinical
syndromes (2 hrs.) ......................................................................................................................... 27
5.9. Preparation of a surgical patient for an operation, correction of homeostasis. Hemocorrectors
(2 hrs.) ............................................................................................................................................ 27
5.10. Radiological diagnostics of the urinary system (2 hrs.) ....................................................... 27
5.11. Intake of drugs in chronic renal failure (2 hrs.) .................................................................... 28
5.12. Drugs affecting urine excretion diuretics (2 hrs.) ............................................................... 28
6. Practical work .............................................................................................................................. 29
6.1. Structure and skeletotopy of the organs of the urinary system (6 hrs.) . Error! Bookmark not
defined.
6.2. Structure and skeletotopy of the organs of the urinary system (6 hrs.) . Error! Bookmark not
defined.
6.3. Histology of the organs of the urinary system (3 hrs.) ........................................................... 31
6.4. Diseases and syndromes of the kidneys and their morphological changes (3 hrs.)................ 32
6.5. Examination of the patients with diseases of the urinary system (4 hrs.) .............................. 34
6.6. Changes in homeostasis of a surgical patient (3 hrs.)............................................................. 34
6.7. Radiological diagnostics of the kidneys and bladder diseases (3 hrs.) .................................. 35
6.8. Drugs affecting urine excretion (3 hrs.).................................................................................. 35
6.9. Renal physiology .................................................................................................................... 36
7. Seminars ....................................................................................................................................... 37
7.2. Molecular principles of ion and water reabsorption in the kidneys, kidney metabolism (2
hrs.) ................................................................................................................................................ 37
7.3. Nephrotoxic factors of occupational environment (3 hrs.) ..................................................... 38
7.4. Main clinical syndromes of the organs of the urinary system (3 hrs.) ................................... 38
7.5. Principles of homeostasis correction of a surgical patient (3 hrs.) ......................................... 39
7.6. Radiological techniques used in the examination of the organs of the urinary system (4 hrs.)
....................................................................................................................................................... 39
7.7. Intake of drugs in chronic renal failure (3 hrs.) ...................................................................... 40
8. Module examination topics:........................................................................................................ 41
8.1. Anatomy ................................................................................................................................. 41
8.2. Histology and Embryology..................................................................................................... 41
8.3. Biochemistry........................................................................................................................... 41
8.4. Physiology .............................................................................................................................. 42
8.5. Pathological Physiology ......................................................................................................... 42
8.6. Pathological Anatomy ............................................................................................................ 42
8.7. Essentials of medical diagnosis .............................................................................................. 43
8.8. Pharmacology ......................................................................................................................... 43
8.9. Radiology................................................................................................................................ 44
8.10. General Surgery .................................................................................................................... 44
8.11. Environmental and occupational medicine........................................................................... 45
9. Appendixes ................................................................................................................................... 45
9.1. Questions for the seminar Molecular principles of ion and water reabsorption in the
kidneys, kidney metabolism (2 hrs.) ............................................................................................ 45
9.2. Questions for the seminar Buffer systems: types, principles of action, reconstitution of
components (3 hrs.)...................................................................................................................... 46
9.3. Questions for the seminar Main clinical syndromes of the organs of the urinary system (3
hrs.) ................................................................................................................................................ 47
9.4. Questions for the seminar Nephrotoxic factors of occupational environment (3 hrs.) ....... 48
9.5. Questions for the seminar Radiological techniques used in the examination of the organs of
the urinary system (4 hrs.) ........................................................................................................... 48
9.6. Questions for the seminar Intake of drugs in chronic renal failure ..................................... 49
1. General information
Supervisor of the module: Lect. Dr. Dalia Akramien, Institute of Physiology and Pharmacology,
dalia.akramiene@lsmuni.lt , tel. 327285
Subjects and responsible persons:
Anatomy (assoc. prof. Inga Saburkina, e-mail: tedeinga@yahoo.com, tel. 864022113)
Human Histology and Embryology (prof. Angelija Valanit, e-mail: angval@kmu.lt, tel.327210,
assoc. prof. Ingrida Balnyt, tel 327282, lect. Jolita Palubinskien, tel 327235)
Biochemistry (prof. L.Ivanovien, 327323, e-mail: ivanoviene@med.kmu.lt,
Physiology (assoc. prof. A. Laukeviiene, ale.laukeviciene@googlemail.com, tel.327285)
Pathological Physiology (lect. Dr. Dalia Akramien, dalia.akramiene@lsmuni.lt, tel. 327285)
Pathological Anatomy (prof. Romualdas Gailys, e-mail: dalia.pangonyte@lsmuni.lt , tel. 787337)
Essentials of Medical Diagnosis (assoc. prof. Palmira Leiyt, e-mail: pleisyte@gmail.com, lect. dr.
Egl Kalinauskien, tel. 306093)
Radiology (assist. Domas Golubickas, radiologijosklinika@kaunoklinikos.lt )
General Surgery of the Organs of the Urinary System (prof. Donatas Venskutonis, e-mail:
donas@medi.lt)
Environmental
and
Occupational
Medicine
(assoc.
prof.
Rta
Ustinaviien,
e-mail:
ruta.ustinaviciene@lsmuni.lt, tel. 327360)

Pharmacology (lect. dr. G. Sakalauskien, tel. 327244, e-mail:
giedrevaldone.sakalauskiene@lsmuni.lt )
2. General contents of the module

Analyzing the problems of this module the students gain new knowledge and apply it to the
following domains:
Anatomy of the organs of the urinary system, blood circulation and innervation;
Histology of the organs of the urinary system;
Physiology of the organs of the urinary system;
Kidney supply with the energy;
Urine filtration and concentration in the kidneys;
Reabsorption of electrolytes, glucose and amino acids in the kidneys;
Role of the kidneys in the control of blood pH;
Control of water balance in human organism;

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Disorders of the urinary system and their pathophysiological mechanisms;
Pathological anatomy of diseases and syndromes of the urinary system;
Fundamentals of examination of the organs of the urinary system;
Homeostasis correction of surgical patients, hemocorrectors;
Essentials of drug pharmacology affecting the organs of the urinary system.
3. Aim and objectives of the module

The student after have studied this module must know how to define, analyze, explain and relate
phenomena to the cases analyzed in the module. Attaining this aim, students must gain knowledge
about the kidney structure, function and disorders in pathological condition, mechanisms and
principles of their examination and treatment.
Kidneys as an organ of homeostasis maintenance (anatomy, morphology, and physiology of

the organs of the urinary system);
Transport function of renal tubules and disorders of this function: transport of calcium,
phosphate, sodium, potassium and water; mechanism of action of diuretics; concentration of
the urine by the kidneys; maintenance of acid-base balance and it disorders;
Reabsorption of electrolytes, glucose and amino acids in the kidneys;
Pathogenesis of the consequences caused by hyperhydration and dehydration; consequences

of water intoxication. Etiology of edema and mechanisms of its pathogenesis;
Disorders of body homeostasis in surgical diseases and causes of endogenous intoxication,

principles of body detoxication and treatment;
Kidney simple cysts and polycystic kidney disease, its pathogenesis morphology and
complications.
Damage of the glomeruli, its pathogenesis, structural changes, mechanisms of progression

and clinical syndromes.
Etiology of nephrolithiasis, pathogenesis, morphological changes, techniques of

examination and principles of treatment;
Pyelonephritis, its pathogenesis, classification, morphology, complications and causes of

death;
Etiology of acute and chronic renal failure, pathogenesis, disorders of the body function,
morphological expressions and principles of treatment.
4. Tutorials
4.1 Case 1. Large kidney
Mr. Harris, age 45, consulted her doctor because the last few weeks he felt dull pain in the lower
back. Recently, the pain became brighter on his right flank.
The doctor detected a painful mass during palpation of right and left lumbar pits. The father of Mr.
Harris died at age 50 years of kidney failure and one of his paternal uncles was suffered a cerebral
vascular accident (radiological examinations had revealed a ruptured aneurysm of a cerebral artery).
The doctor request complementary examinations. Radiological and echographical examinations
showed increased size of both kidneys containing many cavities with fluid. Similar cavities are also
present in the liver. Laboratory tests reveal a plasma creatinine was 80 mol / l (normal 56-115
mol/l).
How could you explain the formation of cavities?

Are they related to the clinical symptoms?
Concept of the problem. Development of the kidney.
Clinical symptoms. Lumbar pain.
Aim
To understand and explain main steps of the kidneys development, macroscopic and microscopic
structure of the kidneys, their innervation and vascular structure as well to understand kidney
function.
Learning objectives and contents

To complete an analysis of this problem the student must know:
Macroscopic structure, sceletotopy and form of the kidneys, their innervation. Vascular system
of the kidneys.
Subject Anatomy
Institute of Anatomy
References:
1. Moore K. L., Dalley A. F. and Agur A. M. R. Clinically oriented anatomy 5th Edition. (2006)
Lippincott Williams & Wilkins, Philadelphia, Baltimore, New York, London, Buenos Aires, Hong
Kong, Sydney, Tokyo, p.p.308-319. Or 6th edition.
Histological structure of the kidney cortical and medullary part. Structure of the nephron.
Histological characteristic of Bowmans capsule and successive segments of the tubules.
Principal steps of development of the kidneys.
Subject - Human Histology and Embryology

Department of Histology and Embryology
References:
1. L.C.Jungeira, J.Carneiro. Basic Histology, McGraw-Hill, 2005, p.p.373 391
2. T.W. Sadler. Langmans Medical Embryology 2000, Lippincott Williams&Wilkins, p.p.304 319
Kidney functions. Physiological anatomy of the kidneys and the bladder. Micturition.
Subject Physiology
Institute of Physiology and Pharmacology
References:
1. Guyton and Hall textbook of medical physiology, 12th ed., Saunders Elsevier; 2011. p. 304 310.
2. W.F.Ganong. Review of Medical Physiology. 22nd ed., McGraw-Hill companies; 2005. p. 699
702.
Pathogenesis, morphology and complications of the simple cysts and polycystic kidney
diseases.
Subject Pathological anatomy

Clinic of Pathological Anatomy
References:
. Kumar V., Abbas A.K., Aster J. Robbins Basic Pathology, with STUDENT CONSULT Online
Access. 9th Editon, Elservier Science 2013
4.2 Case 2. Low weight of the baby

J.Z., a 25-year-old female with her 3 months old baby (boy) visited the pediatrician for a routine
checkup. The baby was full-termed, the course of delivery was normal, the babys current weight is
3 380 g. The boy is the second child in the family; he has a 2-year-old sister. As the mother notes,
the boys behavior differs from that of his sister when she was at his age. The boy eats poorly (he is
nursed with breast milk) and constantly falls asleep while being fed. During the examination the
physician observed: small weight (4 100 g at 3 months of age) and tachypnea. No other
irregularities were observed. Despite the recommendations to continue nursing, the condition has
not improved. Therefore, the boy was hospitalized because acid-base disorder was suspected.
Blood tests: Na+ 138 mmol/l (normal 135-148), K+ 2.5 mmol/l (normal 3.1-4.6), chlorides 110
mmol/l (normal 95-105), urea 3.5 mmol/l (normal 2.0-7.2 for children up to 1 year), creatinine 32
mmol/l (normal 19-54 for children up to 1 year), blood pH 7.29 (normal 7.33-7.45 in arterial blood,
7.36-7.42 in venous blood). Partial pressure CO2 3.59 kPa (normal 4.2-6), bicarbonates 12 meq/l
(normal 23-30).
Urine test: specific gravity 1.006 (1.015-1.020), pH 7, proteins, nitrites, leukocytes, glucose were
not detected, sodium 35 mmol/l, potassium 25 mmol/l, chlorides 95 mmol/l.
What are the causes and mechanisms of low weight of the baby?
Explain the findings: pH, partial pressure of CO2 and bicarbonate.
What are potential outcomes of acid-base disorder and principles of that disorder elimination?
Concept of the problem. Regulation of blood pH.

Clinical symptoms. Low weight of the baby.
Aim
To understand and explain maintenance of acid-base balance, the etiology of acid-base disorders,
pathogenesis and principles of correction.

To complete an analysis of this problem the student must know:
To understand the mechanisms of acid-base balance maintenance and causes of their disorders.
To explain the concept of acidosis and alkalosis, molecular mechanisms of development and
consequences.
9
Subject Biochemistry
Department of Biochemistry
References:
1. Gas transport and pH regulation. In book MD. Devlin. Textbook of biochemistry with
clinical correlations. Wiley-Liss; 4th ed, 1997. p. 1036-1052.
2. WillsBiochemical basis of medicine, 3rd ed. B. Gillham, D.K. Papachristodoulou, J.H.
Thomas, Butterworth-Heinemann, 1997, p.238-241.
Additional readings:
1. Marks basic medical biochemistry: a clinical approach, 2nd C Smith, AD Marks, DB.M
Lieberman. Ed, Lippincott Williams&Wilkins, 2005, p. 41-53.
2. Clinical chemistry, 5th WJ Marshal, SK Bangert, ed. Mosby, 2004, p. 41-61.
3. Pathophysiology of disease: introduction to clinical medicine, 4th ed. SJ McPhee, VR
Lingappa, WF Ganong. Lange Medical books/McGraw-Hill, 2003, p. 459-460.
Defending against changes of acid base balance: buffers, lungs and kidney. Renal control of
acid base balance. Mechanisms of bicarbonate reabsorption in the proximal tubules and in
the loop of Henle, mechanisms of reabsorption and secretion in the distal tubules and the
collecting ducts, mechanisms of hydrogen ion secretion, mechanisms of ammonia reserve
formation and transport, its impact on acidosis/alkalosis correction.
Subject Physiology
References:
2. W.F.Ganong. Review of Medical Physiology. McGraw-Hill Companies. 22nd ed., 2005. p. 720723.
The causes of inherited and acquired proximal (Type II) and distal (Type I and IV) tubular
acidosis. Changes of body functions and mechanisms of its development during acid-base
imbalances.
Subject Pathological physiology

References:
1. http://kidney.niddk.nih.gov/kudiseases/pubs/tubularacidosis/
10
2. Pathophysiology; Lee-Ellen C. Copstead and J.L. Banasik, 5th ed. Saunders Elsevier 2013; p.
543-548.
3. Pathophysiology: The Biologic Basis for Disease in Adults and Children. McCanceKL, Huether
SE 6th ed. St. Louis: Mosby; 2010. p. 117-123.
Etiology and pathogenesis of acid-base balance disturbances in surgical patients. Methods for
detection, principles of correction.
Subject General Surgery

Clinic of General Surgery
References:
1. Schwartzs Principles of Surgery. 9th edition. McGraw-Hill Medical; 2010. p.60-66.
1. Essentials of General Surgery. Fourth edition. P.F.Lawrence. Lippincton Williams &Wilkins.
2006. P.43-66.
2. Sabiston Textbook of Surgery. 18th edition. Saunders Elsevier. 2008. P. 69-94.
11
4.3 Case 3. Color of the urine like Coca-cola

Patient A.S., a 8 years old girl, is brought to the physician because of fever, nausea, oliguria,
puffiness around the eyes, frequent micturition and the color of the urine similar to the drink Cocacola.
Her mother states that the daughter was a healthy child. The mother said that two weeks ago the girl
had returned from a school with a sore throat. Therefore, she didnt attend classes for two days and
afterwards medical advice was sought.
Objective examination revealed: temperature 39C; arterial blood pressure 130/84 mm Hg,
respiration and pulse rate is normal. Periorbital edema of the tissues is observed, and a mild
tenderness in the lumbar area is present.
Laboratory blood test: the amount of urea and creatinine level are slightly increased; reduced C 3,
cryoglobulin is present, and an elevated antistreptolysin O(ASO) titer. Analysis of urine reveals
moderate proteinuria (to 3 g/l) and hematuria (100 erythrocytes in the visual field).
What pathology could be thought of and what tests might be the most informative?
In what way is the immune system involved in the etiology of kidney damage and what is the
pathophysiological mechanism of pathology occurrence?
What are the potential complications, are there any potential causes of death, if any, what are they
and what are the main principles of treatment?
Concept of the problem. Glomerulonephritis.

Clinical symptoms. Fever, proteinuria.
Aim
To understand and explain the etiology of glomerulonephritis and acute renal failure, pathogenesis,
disorders of the body function, morphological changes, peculiarities of examination and principles
of treatment.

To complete an analysis of this problem the students must know:
Histophysiology of the urine formation, structure and function of the urine filtration barrier.
Histological structure of juxtaglomerular apparatus.
Subject Human Histology and Embryology

12

References:
1. Basic Histology, Luiz Carlos Junqueira, Jose Carneiro 2005, 11th Edition, p. 373-392.
2. Wheaters Functional Histology, fourth edition 2000, Barbar Young, John W.Heath, p. 286-309.
3. Human Histology, third edition. 2003 Alan Stevens, James S.Lowe, p. 293-321.
4. Concise histology, second edition. 2003 Bloom, Fawcetts, p. 237-246.
5. Color Textbook of Histology, second Edition, 2001,Leslie P.Gartner, James L.Hiatt.
Regulation of the renal blood flow, mechanisms of glomerular filtration and it regulation,
tubulo-glomerular feedback. Glomerular filtration rate (GFR). GFR detection using renal
clearance method.
Subject Physiology
References:
1. Guyton and Hall textbook of medical physiology, 12th ed., Saunders Elsevier; 2011. p. 312 321;
340 342.
2. W.F.Ganong. Review of Medical Physiology, McGraw-Hill Companies, 22nd ed., 2005. p.702708.
Biochemical principles of renal function and significance to homeostasis. Biological role of

urea and creatinine and molecular mechanisms of synthesis. Structure and effects of the
hormones of renin-angiotensisn-aldosteron system.
References:
1. D.K.Papachristodoulou, J.H.Thomas, Butterworth-Heinemann, 1997, p.230-236.
2. Textbook of biochemistry with clinical correlations. Wiley-Liss; 4th ed. Devlin MD. 1997,
p.1043-1052
1. Textbook of biochemistry with clinical correlations. Wiley-Liss; 6th ed. Devlin MD. 2005.
2. Medical biochemistry. Mosby; 2nd ed. Baynes JW, Dominiczak MH. 2004.
13
Etiopathogenesis of the changes in glomerular filtration and output of the urine. Changes in
composition of the urine with glomerulonephritis. Pathogenesis of nephritic and nephritic
syndrome. Etiology and pathogenesis of acute renal failure.
Subject Pathological Physiology

References:
1. Pathophysiology, L.E.C. Capstead, J.L. Banasik, 5th ed. 2013. p. 586-590, 594-601.
2. Pathophysiology (The Biologic Basic for Disease in Adults and children), K.L. McCance, S.E.
Huether, 6th ed, 2010. p. 1378-1389.
Damage of the glomeruli, its pathogenesis, structural changes, mechanisms of progression and
clinical syndromes.
Pathogenesis, morphology and clinical course of the hematuria/nephritic syndrome causing

(most frequently) by acute proliferative (poststreptococcal, postinfectious) glomerulonephritis.
Pathogenesis morphology and clinical course of the rapidly progressive (crescentic)
glomerulonephritis. Pathogenesis, morphology and clinical course of the proteinuria/nephrotic
syndrome causing (most frequently) by membranous nephropathy, minimal-change disease,
focal
segmental
glomerulosclerosis
and
membranoproliferative
(mesangiocapillary)
glomerulonephritis (causing mixed symptoms syndrome).

Subject Pathological Anatomy
References:
1. Kumar V., Abbas A.K., Aster J. Robbins Basic Pathology, with STUDENT CONSULT Online
Access, 9th Edition, Elselvier Science 2013.
2.
Atlas
of
Histopathological
Slides
for
Problem-Based
Learning
(http://www.pathonet.lt/atlasas_en/a2ks63.htm)
3. Virtual microscopy for practical works (http://www.pathonet.lt/moodle/course/view.php?id=34).
How detect nephritic syndrome. Main symptoms and differences of nephritic and nephrotic
syndrome. Changes in micturition and urinary output, their clinical meanings. Creatinine
clearance, it normal and pathological values, clinical meanings.
Subject Essentials of Medical Diagnosis
14
Clinic of Internal Diseases

References:
1.
Harrisons Principles of Internal Medicine, 2012.
2. Clinical examination /Owen Epstein ... [et al.]. Edinburgh [etc.] : Mosby Elsevier, 2008
1. The Merck Manual of diagnosis and therapy/R.S.Porter, editor-in-chief; J.L.Kaplan, senior
assistant editor;editorial board: R.K.Albert...[et al.], 2011.
2. http://www.emedicine.com/med/NEPHROLOGY.htm
3. Propedeutics to Internal medicine. Compiled by Egidijus Bacevicius. Kaunas, 1998, p.218, 224228, 235-236.
Techniques of kidney ultrasound examination for diagnosing glomerulonephritis, clinical

value of kidney ultrasound findings.
Subject Radiology
Clinic of Radiology
References:
Ultrasound teaching manual, Matthias Hofer, Thieme, 1999, p. 37 46.
15
4.4 Case 4. Edema of the body.

B.Z., a 55-year-old heavily smoking patient, a week ago suddenly developed the symptoms of loss
of perception and increase of weight. During physical examination swelling of the body is observed,
and disorder of perception is determined.
Laboratory blood tests: Na+ 118 mmol/l (normal 135-148), plasma osmolarity 242 mosm/kg H2O
(normal 285-295 mosm/kg H2O). Urine test: Na+ 60 mmol/l and urine osmolarity 450 mosm/kg
H20.
The physician advised the patient to limit water intake (less than 1 liter per day). Despite the
recommendations, after a week the patient complained of perception disorders, nausea and
vomiting. Laboratory tests: Na+ 119 mmol/l, osmolarity 245 mosm/kg H2O.
During the X-ray examination the increase of pulmonary size was determined.
Explain the etiology and pathogenesis of the disorder.

Explain the clinical symptoms on the basis of laboratory findings.
Explain the pathogenetical mechanisms of edema formation.
Concept of the problem. Osmoregulation.

Clinical symptoms. Accumulation of water and increase of body weight.
Aim
To learn mechanisms of water and Na+ balance regulation, the causes and types of this balance
disorders, and principles of its correction.

Mechanisms of water and electrolyte balance maintenance. Structure and mechanism of action
of vasopressin and natriuretic peptides.
References:
16
1.
Harpers Biochemistry. 24th ed. R.K.Murray, D.K. Granner, P.A.Mayes, V.W.Rodwell.

Prentice-Hall International, 1996, p.530-532; 549; 557-559.
2. Basic medical biochemistry: a clinical approach. DB. Marks, AD. Marks, CM. Smith.
Williams Wilkins, 1996, p. 719-725
1. Clinical chemistry, 5th ed., Mosby. WJ Marshal, SK Bangert 2004, p. 13-39.
2. Textbook of biochemistry with clinical correlations. MD Devlin. Wiley-Liss; 6th ed, 2006, p.
920-921, 925-935.
Body osmoregulation, the role of osmo- and baroreceptors in this process, mechanisms of
vasopressin secretion; impact of vasopressin on transport of water and its basic principles of
physiological activity; specificity of sodium and water transport in separate parts of renal
tubules; urea recirculation and mechanisms of its transport; mechanisms of urine concentration
and dilution, countercurrent mechanism.
Subject Physiology
Institute of Physiologyand Pharmacology
References:
2. W.F.Ganong. Review of Medical Physiology. McGraw-Hill companies, 22nd ed., 2005. p.713720.
Pathogenesis of consequences caused by positive and negative water balance, consequences of

water intoxication, etiology and pathogenesis of edema formation.

References:
1. Pathophysiology, L.E.C. Capstead, J.L. Banasik, 5th ed. 2013; p. 520-528, 415, 765.
Huether, 6th ed. 2010, p. 96-106, 1384, 1482-1483.
Etiology and pathogenesis of body fluid and electrolyte balance disturbances in surgical
patients. Types, methods for detection, principles of correction.
Subject General Surgery

17

References:
Principles of surgery. Fifth edition. Schwartz, Shires, Spencer, Storer. McGraw-Hill Book
Company; 1996. p. 65-70;75-87.
1. Principles and practice of Surgery. Garden O.J., Bradbury A.W., Forsythe J., Haddock G.
Churchill Livingstone; 2002. p.10-18.
2. Surgery. Jarrell Bruce E., Carabasi R. Antony. Pensylvania, USA: Harwal Publishing
Company; 1986. p.15-17;18-22.
Drugs affecting urine excretion (diuretics), their classification taking into consideration
mechanisms of action and chemical composition. The most important representatives of
separate classes of medicinal preparations, their mechanisms of action, clinical effect,
pharmacokinetic properties, main clinical usage, side effects.
Subject Pharmacology
References:
1. Lippincotts Illustrated Reviews: Pharmacology. 4th edition. Harvey R. A., Champe P.C. et al.
Philadelphia:Walters Kluwer/Lippincott Williams & Wilkins 2009; p. 261-274 (other editions are
appropriate).
2. Basic and Clinical Pharmacology 11th Edition. Katzung B.G., Masters S.B., Trevor A.J.
Singapore:McGrawHill/Lange 2009, p. 251-270 (other editions are appropriate).
Additional readings
1. Pharmacology. Fifth edition. Rang H.P. Dale M.M. et al. Edinburgh: Churchil Livingstone 2003;
p. 352-366.
2. Katzung & Trevors Pharmacology examination & board review. Eighth Edition. Trevor A.J.,
Katzung B.G., Masters S.B. Singapore:McGrawHill/Lange 2008, p. 132-42 (other editions are
appropriate).
3. Pharmacology. Third Edition. Brenner G.M., Stevens C.W. Philadelphia:Saunders Elsevier 2010,
p. 130-139.
18
4.5 Case 5. Blood in urine

A.J., a 38-year-old patient, having arrived at the emergency room complains of an intense pain
(colic) in the right lumbar area that spreads down into the groin. The pain developed suddenly at
night, woke him up and lasted for about 40 minutes. The pain was intermittent. The patient didnt
mention either painful, more frequent micturition, or fever and chills. The patient was nauseous,
vomiting, there was some blood noticed in the urine. It was discovered from the anamnesis that the
patient had been suffering from a nervous stress, smoked heavily, drank a lot of coffee, and had
inadequate nutrition. He denies taking alcohol or drugs. According to the familial anamnesis his
father and his fathers grandfather suffered from nephrolithiasis, and the mother had arterial
hypertension.
Objectively positive Jordans symptom on the right side. Spasmolytic drugs relieve pain.
Temperature 37.0C; respiration rate 22 breaths/min., arterial blood pressure 145/90 mm/Hg,
pulse rate 100 beats/min.
Laboratory blood test: Hb 148 g/l; erythrocytes. 5.01012/l; leukocytes. 12109/l.
Laboratory urine test - 200 erythrocytes in the visual field (hematuria).
Echoscopy readings collector system of the right kidney is extended up to 4.0 cm in width.
X-ray examination: the shadow of concrement detected in the third part of the right ureter.
Explain the pathophysiological mechanisms of the pain and changes in the urine.
What pathological processes do you think are involved, and what diagnostic tests would be the most
informative?
What are the potential complications and causes of death, if there are any, what are they and what
are the main principles of treatment?
Concept of the problem. Formation of calculi in the urinary system.

Clinical symptoms. Pain in the lumbar area, hematuria.
Aim
To know the structure of the ureters, their constricted sites, innervation. To understand causes of
nephrolithiasis, mechanisms calculi formation and it relation with urine pH, techniques of patient
examination, principles of treatment.

19
Sceletotopy of the ureters, sites of the constriction and peculiarities of their innervation.
Subject Anatomy
References:
Moore K. L., Dalley A. F. and Agur A. M. R. Clinically oriented anatomy 5th Edition. (2006)
Lippincott Williams & Wilkins, Philadelphia, Baltimore, New York, London, Buenos Aires, Hong
Kong, Sydney, Tokyo, p.p 313, 391, 394, 396. Or 6th edition.
Mechanisms and regulation of calcium, magnesium, phosphate, sulfate and organic acids
transport in the nephron.
Subject Physiology
References:
1. Guyton and Hall textbook of medical physiology, 12th ed., Saunders Elsevier; 2011. p. 329 330;
367 370.
2. W.F.Ganong. Review of Medical Physiology. McGraw-Hill Companies. 21th ed., 2005. p. 708713.
Causes of nephrolithiasis, mechanisms of calculi formation and it relation with pH of the

urine. Pathogenesis of complications in nephrolithiasis.

References:
1. Pathophysiology, L.E.C. Capstead, J.L. Banasik, 5th ed. 2013; p.581-586, 621-622.
Huether, 6th ed. 2010, p. 1365 -1378.
Urolithiasis, its pathogenesis, morphology, complications and causes of death. Pyelonephritis,

its pathogenesis, classification, morphology, complications and causes of death.
20

References:
2.
Atlas
of
Histopathological
Slides
for
Problem-Based
Learning
What examination techniques should be used to detect nephrolithiasis. Standards of the urine
tests and pathological values of quantative and qualitative change.
Subject Essentials of Medical Diagnostics

References:
1. Harrisons Principles of Internal Medicine, 2012.
3. Propedeutics to Internal medicine. Compiled by Egidijus Bacevicius. Kaunas, 1998.
Possibilities of different radiological techniques (x-ray examination, ultrasound, computed

tomography) for diagnosing nephrolithiasis, assessment of the examination findings.
Subject Radiology
Clinic of Radiology
References:
1. Essential radiology, Richard B. Gunderman, Thieme, 2006, p. 147 171.
2. Ultrasound teaching manual, Matthias Hofer, Thieme, 1999, p. 37 46.
Additional reading:
1. Fundamentals of Body CT, Third edition, W. Richard Webb, William E. Brant, Nancy M. Major,
Saunders Elsevier, 2006, p. 273 302.
21
4.6 Case 6. Sweet urine

A.B., an 82-year-old female with chronic diabetes mellitus seeks medical help because of shortness
of breath and palpitation. Her niece explained the course of the patients disease. It was discovered
that hemodialysis had been performed three times a week over three recent years. Type II diabetes
mellitus was determined when she was 49, and currently she takes insulin. From the family
anamnesis (medical history) it turned out that her sister, brother and mothers grandfather suffered
from diabetes mellitus as well. Hemodialysis was performed on her mother for the first time when
she was 65, and after 10 years she died of renal failure. Her grandfather died from a heart attack
aged 62.
Examination: temperature 40C, respiration rate 23 breats/min, arterial blood pressure 155/91
mmHg, pulse rate 102 beats/min. The patient is obese, she looks her age. Respiration in the apex of
the right lung is weakened, rales are auscultated, friction of pericardium is present on the left and
lower lateral side of the breastbone. Cyanosis is not observed, there are no edema in the limbs
except subcutaneous edema in both knee joints.
Laboratory blood tests: glucose 15.57 mmol (normal 3.33-5.55), Na+ 146 mmol/l, K+ 5.2
mmol/l, Cl- 90 mmol/l, HCO3- 5 mmol/l, urea 39 27 mmol/l and creatinine 442 mol/l; Hb
80 g/l; Ht 0.24, thrombocytes 150109/l, blood culture 2: E. Coli sensitivity is not determined;
urine test glucose +++, no ketones, proteins+, nitrites+, leukocyte esterase+, blood 2+, a lot of
precipitates.
Explain the causes of chronic renal failure, the disorders of body function and morphological
expressions.
What are the potential complications of other organs and their systems and causes of death?
Principles of treatment in renal failure and its effects on pharmacokinetics and pharmacodynamics.
Concept of the problem. Renal failure.

Clinical symptoms. Uremia, glucosuria.
Aim
To understand and explain the causes and pathogenesis of chronic renal failure, changes in the
body, techniques of examination and principles of treatment.

22
Causes and pathogenesis of chronic renal failure. Mechanisms of changes in the balance of
body fluids and electrolytes, changes in the skin, skeleton, blood, and in the cardiovascular,
immune and nervous systems in chronic renal failure.

References:
1. Pathophysiology, L.E.C. Capstead, J.L. Banasik,5th ed. 2013. p. 601-607.
Huether, 6th ed. 2010. p. 1389-1398.
Morphology and clinical course of chronic glomerulonephritis. Morphological manifestations

of the kidney failure (uremic syndrome).

References:
2.
Atlas
of
Histopathological
Slides
for
Problem-Based
Learning
Examination methods of the patient and detection of chronic renal failure syndrome.
Subject Essentials of Medical Diagnosis

References:
1.Harrisons Principles of Internal Medicine, 2012.
2.Clinical examination /Owen Epstein ... [et al.]. Edinburgh [etc.] : Mosby Elsevier, 2008
23
3. Propedeutics to Internal medicine. Compiled by Egidijus Bacevicius. Kaunas, 1998.
The impact of renal failure on pharmacokinetics and pharmacodynamics; principles of drug

dosage to the patients with renal failure. Drugs used to treat clinical symptoms of renal failure.
To know excretion of drugs and their nephrotoxic effect.
Subject Pharmacology
References:
appropriate).
Additional readings
p. 352-366.
appropriate).
p. 130-139.
Techniques of ultrasound examination of the kidneys for diagnosing renal failure, clinical
value of ultrasound findings.
Subject Radiology
Clinic of Radiology
References:
24
5. Lectures
5.1 Structure of the organs of the urinary system (2 hrs.)
Responsible person assoc.prof. I. Saburkina
Description
Kidneys. Their skeletotopy, lobar and horseshoe form. Descended kidney. Macrostructure of the
kidneys: cortex, medulla, blood vessels, nerves. Kidney coating. Ureters: topography, structure,
constrictions, blood vessels, nerves. Bladder skeletotopy, structure, blood vessels, nerves. Bladder
fixation. Urethra: its topography, structure, blood vessels and nerves.
5.2 Histophysiology of the organs of the urinary system (2 hrs.)

Responsible person prof. A.Valanit
Description
Development of the urinary system. Principal functions of the kidneys. Morphological structure of
the kidneys. Structure of the nephron: glomerulus. Histological structure of Bowmans capsule, the
nephron tubules and collecting ducts. Histological structure and function of the juxtaglomerular
apparatus. Structure and function of the urine filtration barrier. Scheme of the urine formation and
histological characteristics of the structure involved in it. Interstitial renal tissue. Histophysiology of
the bladder and ureter.
5.3 Role of kidneys in homeostasis (2 hrs.)

Institute of Physiology and Pharmacology (Physiology)
Responsible persons assoc.prof. A. Laukeviien
Description
Renal functions. Mechanisms of glomerular filtration, glomerular filtration rate and its
determination. Clearance and its peculiarities. Function of the renal tubules. Mechanisms of urine
concentration and dilution. Renal control of acid-base balance. Micturition.
25
5.4 Regulation of water and electrolyte homeostasis with hormones (2 hrs.)

Responsible person prof. L.Ivanovien
Description
Structure of mineralcorticoids, synthesis, regulation of secretion, molecular mechanisms of
aldosterone action, cellular targets, secretion disturbances, renin-angiotensin system, structure of
vasopressin, regulation of secretion, cellular targets, molecular mechanisms of action, disturbances
of secretion and action, types of atrial natriuretic peptides (ANP), secretion, molecular mechanisms
of action will be analyzed. Role of antidiuretic hormone (vasopressin) in regulation of water
balance. Molecular mechanism of antidiuretic hormone action.
5.5 Disorders of renal functions. Changes in urine excretion and composition.

Acute and chronic renal failure, etiology, mechanisms of pathogenesis,
disorders of body functions (2 hrs.)
Institute of Physiology and Pharmacology (Pathological Physiology)
Responsible persons lect. dr. D.Akramien
Description
Disorders of renal function, their etiology, consequences. Filtration disorders of renal glomeruli.
Changes in urine excretion and composition. Acute and chronic renal failure, etiology, mechanisms
of pathogenesis, disorders of body function.
5.6 Structural principles of homeostasis and pathology of the organs of the

urinary system (2 hrs.)
Department of Pathological Anatomy
Responsible persons prof. R. Gailys
Description
Principles of classification of diseases and syndromes of the urinary system. Morphological
expressions of the most common lesions of diseases of the urinary system, complications and
causes of death. Morphology of renal failure syndrome.
26
5.7 Environmental factors, influencing homeostasis and renal function (2 hrs.)

Department of Environmental and Occupational Medicine
Responsible person assoc.prof. R.Ustinaviiene
Description
Environmental factors (physical, chemical) influencing human body homeostasis and the urinary
system. Chemical pollutants, drinking water quality, food additives. Metereological factors
influencing renal function and homeostasis.
5.8 Examination of the patients with diseases of the urinary system: interview,
inspection, palpation, percussion, auscultation. Laboratory and
instrumental diagnosis. Main clinical syndromes (2 hrs.)
Responsible person assoc. prof. P. Leiyt
Description
Examination of the patients with diseases of the urinary system. The most important aspects of
anamnesis (interview) and objective examination (inspection, palpation, percussion, auscultation).
Principal laboratory (urinalysis, blood biochemistry, measurement of glomerular filtration rate) and
instrumental tests . Main clinical, morphological and functional syndromes (renal edema, renal
hypertension, nephritic syndrome, nephrotic syndrome, acute and chronic renal failure).
5.9 Preparation of a surgical patient for an operation, correction of homeostasis.

Hemocorrectors (2 hrs.)
Responsible persons lect. S.Bradulskis
Description
Types of body homeostasis disorders. Etiology and pathogenesis of water, electrolyte, acid-base
disorder in surgical diseases, types, ways of determination, principles of correction. Corrections and
principles of replacement and maintenance therapy. Hemocorrectors.
5.10 Radiological diagnostics of the urinary system (2 hrs.)

Department Clinic of Radiology
27
Responsible person assist. M. Strainskas

Description
Radiological imaging of the organs of the urinary system. Comparative value of various techniques
radiography, ultrasound, computed tomography, magnetic resonance imaging, scintigraphy,
angiography for diagnosing diseases of the urinary system.
Significance, impact, side effects of the intravenous contrast media and radiopharmaceuticals used
in radiological examination of the kidneys.
Early radiological diagnostics of oncological diseases of the urinary system.
Application of the most modern technologies to the radiological diagnostics of the urinary system.
5.11 Intake of drugs in chronic renal failure (2 hrs.)

Institute of Physiology and Pharmacology (Pharmacology)
Responsible person lect. G. Sakalauskien
Description
An impact of renal function failure on drug pharmacokinetics and pharmacodynamics. Principles of
drugs dosage to the patients with renal failure are explained. Mechanisms of drug excretion through
the kidneys are analyzed. Information about nephrotoxic effect of drugs is presented.
5.12 Drugs affecting urine excretion diuretics (2 hrs.)

Description
Diuretics - drugs stimulating the urine excretion. Five main groups of diuretics: carbonic anhydrase
inhibitors, osmodiuretics, loop diuretics, thiazides, aldosterone antagonists are described.
Mechanism of action of each drug group, site of effect and triggered pharmacological effect are
discussed. Information about the properties of the most important representatives of separate classes
of drugs, indications and side effects are presented.
28
6. Practical work
6.1 Anatomic structure of the kidneys and ureters (3 h.)
Unit Institute of Anatomy
In charge of associated professor I. Saburkina
Purpose
To apply the knowledge about the morphology, the topography, the innervation and vascularisation
of the kidneys and ureters in further clinical studies and practice.
Objectives
To prepare and present the ppt presentations using skeleton, organs, models and posters on given
topics:
1. The skeletotopy and organotopy of the kidneys.
2. The renal capsules and the path of extension of perinephric abscess.
3. The significance of morphological peculiarities of the renal fascia in the nephroptosis.
4. The blood vessels and lymph drainage of kidneys.
5. The nerve supply of kidneys.
6. The congenital anomalies of kidneys.
7. The topography and morphology of ureters. The structures that cross the male and female
ureters.
8. The anatomical constrictions of ureters and their significance in the migration of the stones.
9. The blood supply of ureters and morphological peculiarities of the approach of arteries of
abdominal and pelvic parts of ureters that are important in surgery.
10. The innervation of ureters and mechanism of pain irradiation during obstruction of ureter by
stones.
11. The congenital anomalies and jatrogenic injuries of ureters.
Review questions:
1. List the muscles which are related to the posterior wall of the kidneys.
2. List the renal capsules and explain their structure and attachment to the adjacent organs.
3. The renal intraorganic blood vessels.
4. Explain the functions of renal sympathetic and parasympathetic nerve fibers.
29
5. List three organs which cross the male ureter and identify the sites of crossing.
6. List four organs which cross the female ureter and identify the sites of crossing.
7. Identify the common sites of jatrogenic injury of ureters during the surgical ligation of
ovarian and uterine vessels.
8. Determine the course (medial or lateral) for the approach of arteries towards the abdominal
and pelvic parts of ureter. Note the surgical significance of the pattern of the arterial
approach.
9. List three anatomical constrictions of ureters and point their sites.
10. The innervation of ureters. To which segments of the spinal cord the pain sensation is
conveyed from the obstructed ureter?
References:
1. Moore K. L., Dalley A. F. and Agur A. M. R. Clinically oriented anatomy 6th Edition.
(2010) Lippincott Williams & Wilkins, Philadelphia, Baltimore, New York, London,
Buenos Aires, Hong Kong, Sydney, Tokyo.
6.2 Anatomic structure of the urinary bladder and urethra (3 h.)

Unit Institute of Anatomy
In charge of associated professor I. Saburkina
Purpose
To apply the knowledge about the peculiarities of the morphology, the blood supply and drainage of
lymph of the urinary bladder, the urethra and prostate in the further clinical studies and practice.
Objectives
To prepare and present the ppt presentations using skeleton, organs, models and posters on given
topics:
1. The topography and fixation of the urinary bladder. The suprapubic cystotomy.
2. The blood supply and lymph drainage of the urinary bladder.
3. The innervation of the urinary bladder.
4. The rupture of the urinary bladder and variants of urine passage.
30
5. The structure, the sphincters, the blood vessels, the lymph vessels and nerves of the female
urethra.
6. The structure, the parts, the sphincters, the blood vessels, the lymph vessels and nerves of
the male urethra.
7. The urethral catheterization in males.
8. The rupture of the urethra and urine passage in males.
Review questions:
1. Explain the topography of the urinary bladder and list ligaments that support the bladder.
2. List the arteries of the male and female urinary bladder.
3. Which group of lymph nodes will most likely become invaded by cancerous cells of bladder
cancer?
4. Explain the functions of sympathetic and parasympathetic nerve fibers of urinary bladder.
5. To which segments of the spinal cord the pain sensation is conveyed from the urinary
bladder?
6. Explain the variants of the urine passage after rupture of the urinary bladder.
7. Describe parts of the male urethra (length, diameter, location, features).
8. List arteries of the male urethra.
9. Explain the variants of the urine passage after rupture of the male urethra.
10. The structure, location, functions and innervation of the sphincters of the male and female
urethra.
References:
1. Moore K. L., Dalley A. F. and Agur A. M. R. Clinically oriented anatomy 6th Edition.
(2010) Lippincott Williams & Wilkins, Philadelphia, Baltimore, New York, London,
Buenos Aires, Hong Kong, Sydney, Tokyo.
6.3 Histology of the organs of the urinary system (3 hrs.)

Description
Histology of the kidneys, ureters, bladder and urethra.
References:
1. L.C. Jungeira, J.Carneiro. Basic Histology, 2005, 11th. Ed., p. 373-391.
31
2. W. Kuehnel, Color atlas of Cytology, Histology and Microscopic Anatomy, 2003, 4 th ed., p.
352-374, 396-399.
6.4 Diseases and syndromes of the kidneys and their morphological changes
(3 hrs.)
Responsible persons prof. D. Pangonyt, prof. V.Lesauskait
Description
Contents:
Categories of the pathologoanatomical diagnoses. Nosological and pathogenetic principles of
diagnosis formulation.
Clinical syndromes if kidney damage. Damage of glomerule, its pathogenesis, structural
changes, mechanisms of progression, classification and clinical carsus.
Pyelonephritis, its pathogenesis and morphology. Urolithiasis.
Polycystic kidney disease.
Morphology of the chronic renal failure (uremia).
Tasks:
1. Analyse morphological changes of the glomeruli damage, paying attention to it illustrating
preparations, discuss on pathogenesis of these changes and possible complications.
2. Study pathogenesis, morphology and complications of pyelonephritis and illustrate it by
preparations.
3. Discuss on mechanisms of development and possible complications of the simple cysts and
polycystic kidney disease.
4. Discuss why kidney diseases can cause systemic arterial hypertension?
5. Choose macropreparations with kidney damage, possible induce kidney failure (uremia).
6. Solve (in written) morphological diagnostic tasks: establish main disease, its morphological
backgraund, mark compensatory processes, indicate complications and possible causes of death.
7. Find out, draw and mark typical pathological changes in the histological slides and electron
micrographs, relate them with macroscopical ones.
Macropreparations
Glomerulonephritis chronica
Hypertrophia ventriculi sinistri cordis
32
Haemorrhagia cerebri
Bronchopneumonia
Urolithiasis: calculus pelvis renalis, pyelonephritis chronica
Pericarditis fibrinosa (uraemica)
Enterocolitis fibrinoso-necroticans uraemica
Pyelonephritis acuta abscedens
Reactio immunica lienis
Glomerulonephritis haemorrhagica
Cystis renum
Polycystosis renum
Electron micrograph
24. Glomerulonephritis endocapillaris diffusa proliferativa (x8500). Capillary lumen is
narrowed because of proliferating endotheliocytes, large deposits (immune complexes) in basal
membrane.
31. Glomerulonephritis (x30 000). Pay attention to the changes of glomerular filter: swelled
endothelium with pinocytic vacuoles, unequaly swelled basal membrane, effaced small foot
processes. Comparise these changes with normal structure of glomerular filter.
Histological slides
48/48a. Glomerulonephritis diffusa extracapillare proliferativa (H+E). Find inflammatory exudate
and cells proliferation (crescents) in Bowman capsule cavity; proteinous casts and erythrocytes in
the lumen of tubules, cytoplasmatic proteinosis in epithelium of convoluted tubules (if it present).
Discuss and mark, which in 48 preparation noticed changes maintain proteinuria, which
hematuria.
What additional investigations supposed to perform after establishing of these histological
changes in kidney biopsy material?
49. Pyelonephritis chronica (H+E). Notice focal infiltration of immune cells (lymphocytes,
macrophages, plasma cells, granulocytes) in the interstitial tissue, granulocytes in the lumen of
tubules and small scars with atrophied tubules. Pay attention to dilated, with atrophical epithelium
tubules, which lumenis filled with proteineous casts, and sclerosated glomeruli and arterias,
arterioles. To what indicate these changes of blood vessels?
References
33
2.
Atlas
of
Histopathological
Slides
for
Problem-Based
Learning
6.5 Examination of the patients with diseases of the urinary system (4 hrs.)
Description
Anamnesis (interview), inspection, palpation, percussion, tapping, auscultation. Laboratory
(urinalysis, blood biochemistry, measurement of glomerular filtration rate) and instrumental
diagnostics.
References:
3. Macleod's clinical examination /edited by Graham Douglas, Fiona Nicol, Colin Robertson ;
illustrated by Robert Britton. Edinburgh : Churchill Livingstone/Elsevier, 2009.
1.The Merck Manual of diagnosis and therapy/R.S.Porter, editor-in-chief; J.L.Kaplan, senior
2.http://www.emedicine.com/med/NEPHROLOGY.htm
3.Propedeutics to Internal medicine. Compiled by Egidijus Bacevicius. Kaunas, 1998.
6.6 Changes in homeostasis of a surgical patient (3 hrs.)

Description
Disorders of acid-base balance. Principles of correction of acid-base balance changes. Observation
of a patient.
References:
Schwartzs Principles of Surgery. Ninth edition. McGraw-Hill Medical; 2010. P.51-60.
34

2006. P.43-66.
6.7 Radiological diagnostics of the kidneys and bladder diseases (3 hrs.)

Clinic of Radiology
Description
Possibilities of radiological diagnostics of nephrolithiasis, nephrocalcinosis, hydronephrosis,
tumours, inflammatory conditions and trauma of the kidney, tumours, stones, inflammatory
conditions of the urinary bladder, comparative value of different radiological techniques.
References:
2. Basic Radiology, Michael Y. M. Chen, Thomas L. Pope, David J. Ott, Lange medical books,
2004, p. 223 245.
6.8 Drugs affecting urine excretion (3 hrs.)

Department of Basic and Clinical Pharmacology
Description
Diuretics. The most important representatives of separate classes of drugs. Mechanism of action,
clinical effect, pharmacokinetic properties, indications, side effects.
References:
appropriate).
35
Additional readings
p. 352-366.
appropriate).
p. 130-139.
6.9 Renal physiology

Institute of Physiology and Pharmacology (Physiology)
Description
The effect of arteriole radius and pressure on glomerular filtration; Renal response on altered blood
pressure; Urine concentration in the kidneys; The effect of hormones on urine formation.
References:
2. W.F.Ganong. Review of Medical Physiology. 22nd ed., McGraw-Hill companies; 2005. p. 699
702.
36
7. Seminars
7.1. Buffer systems: types, principles of action, reconstitution of components(3
hrs.)
Description
Concepts of acid-base equilibrium. Buffer action, buffer chemistry: composition of buffer system,
main terms which characterize efficiency of a buffer. Physiological buffer systems: types of the
buffer systems, origin of their components, loss of the components and their reconstitition.
Laboratory examinations of acid-base equilibrium. Role of the kidney in retain of bicarbonate ion
and reconstitution of bicarbonate buffers system capacity.
References:
1. Medical Biochemistry. Elsevier Mosby; 2nd ed. John W Baynes and Marek Dominiczak. 2005; p.
315-341.
2. Clinical chemistry, 5th ed, Marshall WJ, Bangert SK. Mosby, 2004, p. 63-84.
3. Pathophysiology of disease: introduction to clinical medicine, 4th ed. McPhee SJ, Lingappa VR.
Ganong WF. 2003, p. 430.
7.2. Molecular principles of ion and water reabsorption in the kidneys, kidney
metabolism (2 hrs.)
Description
Kidney as a principle organ implicated in the regulation of homeostasis in humans. Energy and
nutrient metabolism in kidney cells. Principles of water reabsorption in kidney (eefects of
hormones): role of ADH, targets of ADH, mechanisms of ADH action in kidney cells.
Mineralocorticoids as a tools of electrolite reabsorption in kidney: synthesis, mechanisms of action,
target cells of mineralocorticoids; regulation of mineralocorticoid synthesis. Natriuretic peptides:
biochemical characteristics, characteristics and tissue specificity of receptors, physiological
responses to natriuretic paptides. Principles of glucose and amino acid reabsorption in kidney,
37
References:
1. Textbook of biochemistry with clinical correlations. Wiley-Liss; 4th ed., Devlin TM. 2006, p.
920-921; 923-925; 925-928; 932-935.
2. Newsholm W., Leech R. Functional Biochemistry in Health and Disease. Wiley-Blackwell. 2009;
p.27; p.105; p.174;
3. R.K. Murray, D.K. Granner, P.A.Mayes, V.W.Rodwell. Harpers Biochemistry. Prentice-Hall
International, 1996 p.530-532, 549, 552-554, 557-559.
4. Marks Basic Medical Biochemistry. A clinical approach. 2nd edd. Smith C., Marks A.D.,
Lieberman M. Lippincott Williams & Wilkins, 2005, p.p. 767-770.
5. Pathophysiology of disease: introduction to clinical medicine, 4th ed, McPhee SJ, Lingappa VR.
Ganong WF. 2003, p. 444 470.
7.3. Nephrotoxic factors of occupational environment (3 hrs.)

Description
Occupational factors of chemical origin, those have a toxic effect on the organs of the urinary
system. Cadmium and other chemicals in the occupational environment, their toxicology.
References:
1. http://www.who.int/ipcs/assessment/public_health/cadmium/en/
2. Yassi A., Kjellstrom T. Basic environmental health, Oxford university press, 2001.
1. http://www.inchem.org/documents/iarc/vol58/mono58-2.html
2. http://www.who.int/ipcs/assessment/public_health/nmr_cadmium.pdf
7.4. Main clinical syndromes of the organs of the urinary system (3 hrs.)
Description
Syndromes: renal edema, renal hypertension, nephritic and nephritic syndromes, acute and chronic
renal failure (causes, clinical symptoms and signs, stages).
References:
38
7.5. Principles of homeostasis correction of a surgical patient (3 hrs.)

Description
Body fluids. Body fluid changes. Disturbances in fluid balance. Loss through the digestive tract.
Concentration changes (Electrolytes). Principles of correction. Hemocorrectors.
References:
Schwartzs Principles of Surgery. Ninth edition. McGraw-Hill Medical; 2010. P. 60-66.
2006. P.43-66.
7.6. Radiological techniques used in the examination of the organs of the urinary
system (4 hrs.)
Clinic of Radiology
Description
Radiological techniques (x ray, ultrasound, computed tomography, magnetic resonance imaging,
angiography, scintigraphy) used for the examination of kidneys and bladder, their indications,
clinical value, opportunities for diagnosing various diseases of this system. Contrast media and
radiopharmaceuticals used in radiological investigation techniques, the probable side effects which
can be caused by them. Early radiological diagnostic opportunities for oncological diseases of the
urinary system.
39
References:
2004, p. 223 245.
7.7. Intake of drugs in chronic renal failure (3 hrs.)

Department of Basic and Clinical Pharmacology
Description
The influence of renal failure on drug pharmacokinetics and pharmacodynamics; principles of drug
dosage to the patients with renal failure. Drug excretion. Nephrotoxic drug effect.
References:
appropriate).
Additional readings
p. 352-366.
appropriate).
p. 130-139.
4. Munar MY, Singh H. Drug dosing adjustments in patients with chronic kidney disease. Am Fam
Physician. 2007;15;75(10):1487-96.
5. Verbeeck RK, Musumba FT. Pharmacokinetics and dosage adjustment in patients with renal
dysfunction Eur J Clin Pharmacol. 2009;65:757-773.
6. Hartmann B, Czock D, Kelier F. Drug Therapy in Patients With Chronic Renal Failure. Dtsch
Arztebl Int 2010;107(37):647-56.
40
8. Module examination topics:

8.1 Anatomy
1. Topography, structure, vascularisation, lymph drainage, innervation and clinically orientated
anatomy of kidneys.
anatomy of ureters.
anatomy of urinary bladder.
anatomy of uretra.
8.2 Histology and Embryology

1. Histological structure of the kidney cortical and medullary part. Histological structure of the
nephron.
2. Histological characteristic of the cells that make up Bowmans capsule and tubules.
3. Histological structure of the juxtaglomerular apparatus.
4. Structure of the glomerular filtration barrier.
5. Histological characteristic of the urinary bladder, ureters and urethra.
8.3 Biochemistry
1.
Aldosteron structure, synthesis and secretion, target cells and mechanism of action.
Disturbances of secretion.
2. Vasopressin (ADH) structure, synthesis and secretion, target cells and mechanism of action.
Disturbances of secretion.
3. Natriuretic peptides, types, secretion, molecular mechanisms of action.
4. Renin-angiotensin system, action mechanisms, and physiological function.
5. Mechanisms of electrolyte re-absorption in kidney, regulation by hormones.
6. Re-absorption of glucose and amino acids in the kidney.
7. The most important buffer systems in human organism: their composition, principles of
action, distribution in various media of human organisms. Renewal of components of buffer
systems.
41
8.4 Physiology
1. Homeostatic mechanisms of the body. Negative feedback control.
2. Renal functions. Structural and functional unit of the kidney. Urine formation in the kidney; the
main stages and mechanisms. Renal blood flow. Autoregulation
3. Mechanisms of glomerular filtration of the kidneys. Glomerular filtration rate(GFR) and its
determination. Factors influencing glomerular filtration. rate.
4. Clearance, its peculiarities and practical application. Use of clearance method to measure GFR
and renal plasma flow.
5. Function of renal tubules; transport processes and their mechanisms. Epithelial transport
mechanisms.
6. Reabsorbtion and secretion along different parts of the nephron (proximal tubules, loop of Henle,
distal tubules and collecting ducts).
7. Renal control of aci-base balance.
8. Regulation of extracellular fluid volume and osmolarity. Mechanisms of urine concentration and
dilution.
9. Mechanisms of micturition and the function of the organs and systems involved.
8.5 Pathological Physiology

1. Negative water balance, causes, types. Changes of the body functions during dehydratation.
2. Positive water balance, causes, types. Intoxication with water. Renal edema, mechanisms of
development.
3. Changes in glomerular filtration, urinary output. Pathological changes in composition of urine.
4. Acute renal failure, etiology, pathogenesis, changes of the body functions.
5. Chronic renal failure, etiology, pathogenesis, changes of the body functions.
6. Nefrolithiasis: etiology, pathogenesis, changes of the body functions.
8.6 Pathological Anatomy

1. Damage of the glomeruli, its pathogenesis, structural changes, mechanisms of progression and
clinical syndromes.
2. Pathogenesis, morphology and clinical course of the hematuria/nephritic syndrome causing (most
frequently) by acute proliferative (poststreptococcal, postinfectious) glomerulonephritis.
3. Pathogenesis morphology and clinical course of the rapidly progressive (crescentic)
glomerulonephritis.
42
4. Pathogenesis, morphology and clinical course of the proteinuria/nephrotic syndrome causing

(most frequently) by membranous nephropathy, minimal-change disease, focal segmental
glomerulosclerosis and membranoproliferative (mesangiocapillary) glomerulonephritis (causing
mixed symptoms syndrome).
5. Morphology and clinical course of chronic glomerulonephritis.
6. Pyelonephritis, its pathogenesis, classification, morphology, complications and causes of death.
7. Urolithiasis, its pathogenesis, morphology, complications and causes of death.
8. Kidney cysts and polycystic kidney disease, its pathogenesis morphology and complications.
9. Morphological manifestations of the chronic renal failure (uremic syndrome).
8.7 Essentials of medical diagnosis

1. The most important complaints of patients with diseases of the uropoetic system, their clinical
meanings.
2. Changes in micturition and urinary output, their characteristics and clinical meanings.
3. Inspection, palpation, percussion of the patients with diseases of the uropoetic system,
pathological findings, causes.
4. Specific gravity of the urine: normal values, pathological changes, their clinical meanings;
protein in the urine: normal values, pathological changes, clinical meanings.
5. Urinary sediment examination: normal and pathological findings, standards, pathological
meanings of quantitative and qualitative changes.
6. Zimnitskys test: indications, method of performance, evaluation, pathological findings and
clinical meanings.
7. Creatinine clearance: definition, method of performance, normal values, pathological findings,
clinical meanings.
8. Main symptoms of nephritic and nephrotic syndrome, clinical meanings.
9. Syndrome of acute renal failure: definition, causes, clinical and laboratory findings, clinical
meanings.
10. Syndrome of chronic renal failure: definition, causes, clinical and laboratory findings, clinical
meanings.
8.8 Pharmacology
1. The influence of renal failure on drug pharmacokinetics and pharmacodynamics.
2. Carbonic anhydrase inhibitors (representatives, mechanism of action, clinical effect,
pharmacokinetic properties, usage possibilities, side effect).
43
3. Osmotic diuretics (representatives, mechanism of action, clinical effect, pharmacokinetic

properties, usage possibilities, side effect).
4. Thiazide and thiazide-like diuretics (representatives, mechanism of action, clinical effect,
5. Loop diuretics (representatives, mechanism of action, clinical effect, pharmacokinetic properties,
usage possibilities, side effect).
6.
Potassium-sparing
diuretics
(representatives,
mechanism
of
action,
clinical
effect,
8.9 Radiology
1. Opportunities of the radiological imaging of the urinary system. Comparative value of the
different techniques.
2 Early radiological diagnostic opportunities for oncological diseases of the urinary system.
3 Indications for computed tomography of kidneys and urinary bladder.
4. Imaging methods used for nephrolithiasis and urinary obstruction.
5. Contrast media and radiopharmaceuticals used in radiological investigation techniques, the
probable side effects which can be caused by them
6. Radiological diagnostics of kidney cancer and cysts (x ray, ultrasound, computed tomography,
magnetic resonanse imaging).
7.
Significance
and
opportunities
of
radionuclide
investigation
of
the
kidneys,
the
radiopharmaceuticals which are used.

8. Potentials of radiological examination of renal blood circulation.
9. Significance and potentials of ultrasound examination of the kidneys.
10. Potentials of ultrasound examination of the urinary bladder.
8.10 General Surgery

1. Body fluids, fluid compartments, factors determining distribution of body fluids. Exchange of
body fluids.
2. Water balance. Ways and causes of fluid loss in the surgical patient. Fluid balance disturbances.
Signs of dehydration.
3. Electrolytes. Distribution of electrolytes. Composition of fluids lost by the surgical patient,
principles of correction.
4. Methods for detection of electrolytes imbalance and principles of correction.
5. Acid-base balance. Maintenance by the pH buffer systems of blood, lungs, kidneys.
44
6. Types of disturbances of acid-base balance. Principles of correction.
8.11 Environmental and occupational medicine

1. What physical environmental factors may influence the functions of the urinary system?
2. Describe the etiology of overheat, a heat stroke, their symptoms and first aid.
3. What environmental pollutants may influence the functions of the urinary system?
9.Appendixes
9.1 Questions for the seminar Molecular principles of ion and water
reabsorption in the kidneys, kidney metabolism (2 hrs.)
Responsible person prof. V.Borutait
Questions:
1. Energy production in kidney: nutrients, characterization of metabolism, energy requirements
of kidney.
2. Structure of antidiuretic hormone (ADH, vasopressin), synthesis and its regulation, target
cells of ADH, characteristics of receptors and molecular mechanism of action, disturbances
of ADH secretion or action.
3. Aldosterone as a representatove of mineralochorticoids. Structure of aldosterone, its
synthesis and secretion, target cells, molecular mechanism of action.
4. Regulation of aldosterone synthesis/sercretion (rennin-angiotensin system): characterisation,
molecular mechanisms, and biological significance.
5. Natriuretic peptides (NUP): types, secretion, NUP receptor characyteristics and mechanisms
of action.
6. Re-absorption of glucose in kidney: biological significance and mechanisms.
7. Re-absorption of amino acids in kidney: biological significance and mechanisms.
References:
1. Textbook of biochemistry with clinical correlations. Wiley-Liss; 4th ed Devlin MD., 2006, p.
920-921; 923-925; 925-928; 932-935.
45
2. Newsholm W., Leech R. Functional Biochemistry in Health and Disease. Wiley-Blackwell. 2009;
p.27; p.105; p.174;
3. R.K. Murray, D.K. Granner, P.A.Mayes, V.W.Rodwell. Harpers Biochemistry. Prentice-Hall
International, 1996 p.530-532, 549, 552-554, 557-559.
4. Marks Basic Medical Biochemistry. A clinical approach. 2nd edd. Smith C., Marks A.D.,
Lieberman M. Lippincott Williams & Wilkins, 2005, p.p. 767-770.
5. Pathophysiology of disease: introduction to clinical medicine, 4th ed, McPhee SJ, Lingappa VR.
Ganong WF. 2003, p. 444 470.
9.2 Questions for the seminar Buffer systems: types, principles of action,
reconstitution of components (3 hrs.)
Responsible person prof. V.Borutaite
Questions:
1. What is acid - base equilibrium? What are mechanisms of its maintenance?
2. Chemistry of buffer systems. Be able to define a buffer system in chemical terms. Give
examples of buffer systems. Explain in which ways we can evaluate efficiency of buffer
action.
3. What physiological bufers systems are charcteristic to humans. Be able to explain
composition of the buffer systems with emphasis on an acid and a base conjugated to that
acid. Be able to give relevant explanation of those buffer systems action under changes of
pH.
4. Contribution of organs to maintenance of the capacity of physiological buffer systems.
5. Laboratory tests used in evaluation of acid base equilibrium. What do they show and how
they are interpreted?
6. Acid base equilibrium disorders in our body. Mechanisms of metabolic acidosis and
alkalosis. Common causes of those disturbaces.
7. Hyperchloremic metabolic acidosis: mechanisms, causes and laboratory diagnostics.
Management of the condition.
References:
1. Medical Biochemistry. Elsevier Mosby; 2nd ed. John W Baynes and Marek Dominiczak. 2005; p.
315-341.
46
2. Clinical chemistry, 5th ed. Marshall WJ, Bangert SK. The kidneys in book Marshall WJ, Bangert
SK. Mosby, 2004, p. 63-84.
3. Pathophysiology of disease: introduction to clinical medicine, 4th ed. McPhee SJ, Lingappa VR.
Ganong WF. Lange Medical books/McGraw-Hill, 2003, p. 430.
9.3 Questions for the seminar Main clinical syndromes of the organs of the
urinary system (3 hrs.)
Responsible person asocc. Prof. Palmira Leiyt
Questions:
1. The most important complaints of patients with diseases of the urinary system, their clinical
meanings.
2. Changes in micturition and urinary output, their characteristics and clinical meanings.
3. Inspection, palpation, percussion of the patients with diseases of the urinary system, pathological
changes, causes.
4. Specific gravity of the urine: normal values, pathological changes, clinical meanings; protein in
the urine: normal values, pathological changes, clinical meanings.
5. Urinary sediment examination: normal and pathological findings, standards, pathological
meanings of quantitative and qualitative changes.
6. Zimnitskys test: indications, method of performance, evaluation, pathological findings and
clinical meanings.
7. Creatinine clearance: definition, method of performance, normal values, pathological findings,
clinical meanings.
8. Main symptoms of nephritic and nephrotic syndrome, clinical meanings.
9. Syndrome of acute renal failure: definition, causes, principal clinical and laboratory changes,
clinical meanings
10. Syndrome of chronic renal failure: definition, causes, principal clinical and laboratory changes,
clinical meanings
11. Causes of renal hypertension and renal eclampsia, the most important clinical and laboratory
changes, clinical meanings.
References:
47
9.4 Questions for the seminar Nephrotoxic factors of occupational

environment (3 hrs.)
Responsible persons assoc.prof. R.Ustinaviciene
To acquaint students with occupational factors of the chemical origin that have a toxic effect on the
organs of the urinary system.
Questions:
1. What are chemical occupational factors or groups of chemical substances that have an effect
on the urinary system?
2. In what working activities, professions are chemical substances used that have an effect on
the urinary system?
3. Individual and organization preventive measures used in prevention from intoxication with
chemical substances?
4. Legal acts, regulating protection from chemical substances in the working place.
References:
Toxicology. C.D.Klaassesn. Casaret and Doulls 2001, p. 491-514.
9.5 Questions for the seminar Radiological techniques used in the examination
of the organs of the urinary system (4 hrs.)
Clinic of Radiology
Responsible person lect. R. Mickeviius assist. M. Strainskas
Questions:
1. Indications of the kidneys and bladder for radiological examination.
48
2. Indications of the kidneys, bladder for ultrasound examination.

3. Indications of the kidneys and prostate for computerized tomography.
4. Indications for digital subtraction renal angiography and endovascular revascularization.
5. Indications for radionuclide examination of the kidneys.
6. X-ray examination of nephrolithiasis and renal obstruction.
7. Ultrasound diagnostics of inflammatory diseases of the kidneys.
8. Computed tomography imaging of kidney cancer and cysts.
9. Opportunities of ultrasound and computed tomography imaging for kidney traumas.
10. Ultrasound semiotics of various nephropathies, and nephrocalcinosis.
11. Ultrasound semiotics of the bladder tumors.
12. Algorithm of radiological examination of the patients with kidney diseases.
13. Potentials of radiological examination of kidney blood circulation.
References:
2004, p. 223 245.
9.6 Questions for the seminar Intake of drugs in chronic renal failure
Questions:
1. Creatinine clearance: its significance for drug dosage in patients with renal failure.
2. Drugs causing nephrotoxicity, possible mechanisms of nephrotoxic effect. Analgesic
nephropathy (definition, etiology, how do we recognize this phenomenon and how do we
have to avoid it).
3. Resistance to diuretics (definition, etiology, how do we have recognize this phenomenon
and how do we have avoid it).
4. Methods of renal replacement therapy [RRT] (hemodialysis, peritoneal dialysis, renal
transplantation: the main principles of application and potential risk for a patient. Principles
of drug dosage applying the renal replacement therapy.
49
References:
appropriate).
Additional readings
p. 352-366.
2. Burton LL, and other editors. Goodman and Gilmans. The Pharmacological Basis of
Therapeutics. 12th edition. 2011; p. 699-701; 975. (other editions are appropriate).
3. Brenner BM, ed. Brenner: Brenner and Rector's the Kidney. 8th ed. Philadelphia, Pa: Saunders
Elsevier. 2007:chap 30. (other editions are appropriate).
4. Munar MY, Singh H. Drug dosing adjustments in patients with chronic kidney disease. Am Fam
Physician. 2007;15;75(10):1487-96.
5. Verbeeck RK, Musumba FT. Pharmacokinetics and dosage adjustment in patients with renal
dysfunction Eur J Clin Pharmacol. 2009;65:757-773.
6. Hartmann B, Czock D, Kelier F. Drug Therapy in Patients With Chronic Renal Failure. Dtsch
Arztebl Int 2010;107(37):647-56.
50

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EUROPOS SJUNGA

Europos Socialinis Fondas

Program of Medicine Studies

HOMEOSTASIS AND EXCRETION

ruta.ustinaviciene@lsmuni.lt, tel. 327360)

2. General contents of the module

Histology of the organs of the urinary system;

Physiology of the organs of the urinary system;

Kidney supply with the energy;

Urine filtration and concentration in the kidneys;

Reabsorption of electrolytes, glucose and amino acids in the kidneys;

Role of the kidneys in the control of blood pH;

Control of water balance in human organism;

Disorders of the urinary system and their pathophysiological mechanisms;

Pathological anatomy of diseases and syndromes of the urinary system;

Fundamentals of examination of the organs of the urinary system;

Homeostasis correction of surgical patients, hemocorrectors;

Essentials of drug pharmacology affecting the organs of the urinary system.

3. Aim and objectives of the module

Kidneys as an organ of homeostasis maintenance (anatomy, morphology, and physiology of

Reabsorption of electrolytes, glucose and amino acids in the kidneys;

Pathogenesis of the consequences caused by hyperhydration and dehydration; consequences

Disorders of body homeostasis in surgical diseases and causes of endogenous intoxication,

Damage of the glomeruli, its pathogenesis, structural changes, mechanisms of progression

Etiology of nephrolithiasis, pathogenesis, morphological changes, techniques of

Pyelonephritis, its pathogenesis, classification, morphology, complications and causes of

How could you explain the formation of cavities?

Learning objectives and contents

Subject - Human Histology and Embryology

Subject Pathological anatomy

4.2 Case 2. Low weight of the baby

Concept of the problem. Regulation of blood pH.

Learning objectives and contents

Subject Pathological physiology

Subject General Surgery

4.3 Case 3. Color of the urine like Coca-cola

Concept of the problem. Glomerulonephritis.

Learning objectives and contents

Subject Human Histology and Embryology

Department of Histology and Embryology

Biochemical principles of renal function and significance to homeostasis. Biological role of

Subject Pathological Physiology

Pathogenesis, morphology and clinical course of the hematuria/nephritic syndrome causing

glomerulonephritis (causing mixed symptoms syndrome).

Subject Essentials of Medical Diagnosis

Clinic of Internal Diseases

Harrisons Principles of Internal Medicine, 2012.

Techniques of kidney ultrasound examination for diagnosing glomerulonephritis, clinical

4.4 Case 4. Edema of the body.

Explain the etiology and pathogenesis of the disorder.

Concept of the problem. Osmoregulation.

Learning objectives and contents

Harpers Biochemistry. 24th ed. R.K.Murray, D.K. Granner, P.A.Mayes, V.W.Rodwell.

Pathogenesis of consequences caused by positive and negative water balance, consequences of

Subject Pathological Physiology

Subject General Surgery

Clinic of General Surgery

4.5 Case 5. Blood in urine

Concept of the problem. Formation of calculi in the urinary system.

Learning objectives and contents

To complete an analysis of this problem the students must know:

Causes of nephrolithiasis, mechanisms of calculi formation and it relation with pH of the

Subject Pathological Physiology