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dr.

Achmad Taruna
,SpPD,FINASIM
Tempat Tanggal Lahir
Palembang, 9 September 1957
Alamat Kantor
SMF Ilmu Penyakit Dalam RSUD dr Abd. Moeloek
Jl. dr. Rivai no. 6 Bandar Lampung
Alamat Rumah
Jl. Singosari no.39 Enggal, Bandar Lampung
Pendidikan
= Dokter, 1984 FK UNSRI Palembang
= Spesialis Penyakit Dalam, 1997 FK Unsri Palembang
= Peserta didik Sp2-Konsultan Ginjal Hipertensi FK Unsri Palembang
Pendidikan Tambahan
Haemodialysis Course 2008, FK UI Jakarta
Pekerjaan
= Dokter Spesialis Penyakit Dalam RSUD dr. Abd. Moeloek

= Dosen LB Fakultas Kedokteran UNILA Bandar Lampung


Organisasi
= Ikatan Dokter Indonesia
= Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia
= Perhimpunan Nefrologi Indonesia
ANATOMI DAN FISIOLOGI GINJAL

Achmad Taruna
DIVISI GINJAL HIPERTENSI
DEPARTEMEN PENYAKIT DALAM FK
UNILA/RSAM
LAMPUNG
POKOK BAHASAN

1. Struktur Ginjal
2. Fungsi Ginjal
3. Gambaran Klinis Penyakit Ginjal
4. Pemeriksaan Penunjang
ANATOMI MAKRO

Ginjal
Pembuluh darah dan Saraf
Sitem drainase Urine

ANATOMI MIKRO
Nefron
Sel interstisial ginjal
Anatomi Ginjal
letak retroperitoneal, pd
dinding posterior
abdominal

Terletak dari T12-L3


vertebral columna,
disamping m. psoas
major

Bagian superior
dilindungi iga 11, 12
Ginjal kanan lebih rendah
dari kiri (karena terdapat
lobus kanan hepar)

~ Panjang 12 cm x Lebar 5
cm x Tebal 2.5 cm

bean-shaped, reddish-
brown organs

kidney levels berubah


sewaktu respirasi dan
perubahan postural
External surface 3 layers of tissue

1. renal fascia (outer)


CT attaches kidney to
posterior abdominal wall
flexible, allows kidney to
move with respiration
covered by layer of fat

2. perirenal fat (middle layer)


protective cushion

3. renal capsule (innermost)


layer of collagen fibres -
barrier against trauma,
infection etc.
kidney hangs suspended by
collagen fibres and packed Martini p 953
in soft cushion of adipose
tissue
PEMBULUH DARAH DAN SARAF

Arteri renalis 3 cabang menuju ginjal

Vena renalis Vena Cava Inferiors

Limfe bermuara ke nodus limfe aorta lateral

Saraf simpatis mempersarafi pembuluh darah ginjal


dan Aparatusjukstaglomerulus sampai ke nefron

Serabut afferen korda spinalis T10,T11,T12


Sirkulasi Darah

Arteri Renalis
Jantung darah ginjal

Merupakan percabangan
langsung dari aorta
abdominalis
Vena Renalis
darah
Ginjal jantung
1,2 L / menit darah mengalir
melalui tiap ginjal (20% dari
volume darah total)
Blood supply to kidney
Sistem Drainase Urine

Sistem pengaliran urine :


2 ginjal - filter darah, produksi urine

2 ureter - transpor urine (ginjal ke bladder)

bladder - reservoir for urine

uretra - transpor urine


Urinary system (Martini 2006 p952)
Ureters
tubes that transport urine from renal
pelvis to bladder

20-30 cm long

muscular walls - peristaltic waves


force urine down to bladder

retroperitoneal

pressure in the bladder compresses


ureter, helps prevent backflow of
urine

(physiological valve) - still allows


urine to flow into the bladder
Bladder

hollow muscular organ


retroperitoneal, posterior to
pubic symphysis

Capacity ~ 300-400 ml
(max = 1000 ml)

empty: looks like a deflated


balloon, rugae
full spherical rises above
abdominal cavity

Males: anterior to rectum,


above prostate
Females: inferior to uterus,
anterior to vagina

Martini p983
Support of bladder

superior surfaces - peritoneum

middle umbilical ligament -


superior border to umbilicus

lateral umbilical ligaments -


sides of bladder to umbilicus

At base, tough ligamentous


bands anchor bladder to pelvic
and pubic bones

Trigone : triangular area bounded


by openings of ureters and exit
to urethra

cystitis - inflammation of the


bladder wall
Urethra
Female ~ 4 cm long
opens to exterior between
clitoris and vaginal opening

Male ~ 20 cm long
passes through prostate
gland

pierces urogenital
diaphragm

enters penis and extends


throughout length
opens at urethral orifice
Micturition reflex:
Stretch receptors stimulated when filled
to ~ 200 ml
afferent fibres to spinal cord
motor neurons to sm in bladder wall
contracts m. detrusor and increases
pressure

need to relax both internal and


external sphincter - external under
voluntary control

if external sphincter does not relax,


internal sphincter remains closed &
sm in bladder wall relaxes again

Once volume exceeds 500 ml,


micturition reflex may generate
enough P to open internal sphincter
leads to reflexive relaxation of
external sphincter
ANATOMI MIKRO GINJAL

NEFRON SEL INTERSTITIAL


Unit fungsional dan Cortex :
anatomi ginjal. 1. Sel fagosit
400.000-800.000 2. Fibroblast like cells
erytropoitin
nefron
Medulla :
Tiap nefron : tubulus
1. Lipid droplets sintesis
dan glomerulus PG
Nephrons: 85% are cortical, 15% are juxtamedullary
Nephrons

Figure 25.5b
The Nephron

Figure 25.4b
Vascular component of nephron
Made up of blood vessels:

1. Glomerulus - network of capillaries within Bowmans


capsule

2. Afferent arteriole - leading into glomerulus

3. Efferent arteriole - leading out of glomerulus

4. Peritubular capillaries - surrounding tubules

5. Vasa recta - specialised loops of blood vessels around long


Loop of Henle (juxtamedullary nephrons)
Renal corpuscle Martini p959
FUNGSI GINJAL

1. Fungsi ekskretori
Menghasilkan urine, yang penting untuk
eliminasi sampah tubuh (hasil metabolik,
toksin).

2. Fungsi Metabolik
Sintesa beberapa hormon dan degradasi
hormon polipeptida (insulin)
Fungsi Eksresi Ginjal

Urine yang dihasilkan dari darah yang


mengalir melalui ginjal, dan terjadi dalam 2
tahap :

1. Filtrasi plasma glomerulus

2. Reabsorbsi dan eksresi dari tubulus


Glomerulus sebagai Filtrasi Barrier

Glomerulus sebagai pleksus anastomosis kapiler yang di


kelilingi olek kapsula Bowman

Kapsula bowman suatu lekukan kapsula dari epitel


tubuler dimana urin di filtrasi

Darah masuk ke kapiler golmerulus ateriol aferen


vasokontriksi arteriol eferen tek. Hidrostatsik yang
tinggi dalam kapiler glomerulus mengerakan air, ion-
ion, dan molekul kecil.
Filtrasi Barrier Glomerulus

1. Sel endotel
sel yang tipis ukuran pori-pori 70 nm dan bermuatan
negatif, oleh karena adanya glikoprotein terutama
podocalyxin
2. MBG (Membran Basal Glomerulus)
bermuatan negatif oleh karena adanya glikoprotein
3. Sel epitel Bowman (podosit)
Mengalirkan filtrat ke tubulus.
Filtration Membrane

Figure 25.7a
Filtration Membrane

Figure 25.7c
Glomerular Filtration Rate (GFR)

Figure 25.9
Fungsi Tubulus

Filtrat urin yang terbentuk di glomerulus tubulus


(reabsorbsi atau eksresi).

Reabsorbsi solut terbesar di tubulus proksimal, dan


komposisi urin yang baik dibentuk di tubulus distal dan
duktus koligentes.

Loop of Henle memekatan urine

Sel tubulus: sel epitel kolumnar untuk transport.


Fungsi tubulus
Tubulus Proksimal
Sel epitel kolumnar yang mempunyai banyak mikrovili.
endositosis
Reabsorpsi secara aktif seperti Na, K, Ca, P, glukosa
dan asam amino.

Loop of Henle
Terdiri dari pars decendens dan pars acendens
Sel kuboid
The Nephron : tubulus

Figure 25.4b
Tubulus distal

Terdiri dari :
Distal convuled tubule ( tubulus contortus distal).

Collecting tubule

Collecting duct : cortical collecting duct, outer medullary


collecting duct, inner medullary collecting duct.
Mechanisms of Urine Formation

Urine formation and


adjustment of blood
composition
involves three
major processes
Glomerular
filtration
Tubular
reabsorption
Secretion

Figure 25.8
Hormon yang bekerja pada ginjal
ADH atau Vasopresin
- Hormon peptida yang dihasilkan kel.hipofisis posterior
- Me reabsorbsi air pada tubulus kolektivus
Aldosteron
- Hormon steroid yang diproduksi oleh korteks adrenal
- Me reabsorbsi natrium pada tubulus kolektivus
Peptida Natriuretik (NP)
- Diproduksi oleh sel jantung
- Me ekskresi natrium pada tubulus kolektivus
Hormon paratiroid
- protein yang di produksi oleh kel. Paratiroid
- me eksresi fosfat, reabsorbsi kalsium, dan produksi
vitamin D
Hormon yang dihasilkan oleh ginjal
Renin
- Protein yang dihasilkan aparatus jukstaglomerulus
- Pembentukan angiotensin II
- Retensi natrium, dan vasokontritor yang kuat.
Vitamin D
- Hormon steroid yang dimetabolisme ginjal 1,25-
dhidroksikolekaliferol.
- berperan me absorpsi kalsium dan fosfat dari usus.
Eritropoietin
- Protein yang di produksi ginjal
- Me pembentukan sel darah merah di sutul.
Prostaglandin
- Diproduksi oleh ginjal.
- efek pada tonus PD ginjal.
Sistem Renin-Angiotensin-Aldosteron

RAA penting untuk


mempertahankan tekanan
darah normal
Renin disekresi oleh sel
juxtaglomerular yang
berada disekitar arteriol
aferen
Sel Juxtaglomerular dan
macula densa membentuk
suatu unit yaitu juxta
glomerular apparatus
Sistem Renin-Angiotensin-Aldosteron
natrium dan/atau Angiotensinogen
JGA Renin
Volume darah di plasma
dan/atau
stimulasi simpatis Angiotensin
Converting Enzyme
Angiotensin I
enzim dari
paru-paru
Angiotensin II
Tekanan Darah (menyebabkan
vasokonstriksi)

reabsorpsi Na Tubulus
Ginjal Aldosteron Korteks Adrenal
reabsorpsi H2O

Volume Darah Tekanan Darah


PENYAKIT GINJAL

GEJALA SALURAN KEMIH


PANAS

KOLIK

SAKIT PINGGANG

DISURIA

POLAKISURIA
GEJALA SISTEMIK

SIFAT : MENAHUN ASIMPTOMATK


KEADAAN LANJUT:
EDEMA
GANGGUAN G.I TRACT
UREMIA
HIPERTENSI
GATAL
GEJALA NEUROLOGIS
PENDEKATAN PENYAKIT GINJAL
EVALUASI
SINDROMA KLINIK PENYAKIT GINJAL
1. Sindroma Nefrotik
2. Sindroma Nefritik Akut
3. GGA
4. GGK
5. ISK
6. Batu Saluran Kemih (BSK)
7. Hipertensi
DIAGNOSIS
PEMERIKSAAN
URINE RUTIN
MIKROBIOLOGI
FAAL GINJAL
FOTO POLOS
PIELOGRAFI INTRAVENA
RPG
MCU
USG
CT SCAN
RENOGRAM
ANGIOGRAFI
HISTOPATPLOGI
LFG/GFR

LFG/GFR adalah mengukur berapa banyak filtrat yang


dihasilkan oleh glomerulus
Merupakan pengukuran paling baik untuk menilai fungsi
eksresi
Filtrasi dipengaruhi oleh aliran plasma , perbedaan
tekanan, luas permukaan kapiler, dan permeabilitas
kapiler
LFG merupakan jumlah dari hasil semua nefron (rata-
rata 1 juta tiap ginjal)
Assessment of Renal Function
Creatinine Clearance
Best way to estimate GFR
GFR = (creatinine clearance) x (body surface area in m 2/1.73)
Ways to measure:
24-hour urine creatinine:
Creatinine clearance = (Ucr x Uvol)/ plasma Cr
Cockcroft-Gault Equation:
(140 - age) x lean body weight [kg]
CrCl (mL/min) = x 0.85 if
Cr [mg/dL] x 72 female

Limitations: Based on white men with non-diabetes kidney disease


Modification of Diet in Renal Disease (MDRD) Equation:
GFR (mL/min./1.73m2) = 186 X (SCr)-1.154 X (Age)-0.203 X
(0.742 if female) X (1.210 if African-American )
Rumus Homer Smith untuk mengukur renal klirens :

C=UXV
P
C = Klirens
U = Konsentrasi zat marker dalam urin
V = Volume urin
P = Konsentrasi zat marker dalam plasma
50 Dr.Sarma@works
Fungsi- Fungsi Ginjal
Menyaring 200 L darah /hari, memungkinkan toksin-
toksin, sampah metabolik dan ion excess keluar dari
tubuh lewat urin

Meregulasi volume dan zat-zat kimia yang terbentuk


oleh darah

Mengatur keseimbangan antara air dan garam, juga


asam dan basa
Fungsi Lain Dari Ginjal
Gluconeogenesis selama puasa

Menghasilkan renin untuk membantu regulasi tekanan


darah dan eritropoetin untuk merangasang produksi sel-
sel darah merah

Aktivasi vitamin D
Nephron
Renal corpuscle Terdiri atas glomerulus dan kapsul
Bowman

Endotel Glomerular fenestrated epithelium that


allows solute-rich, virtually protein-free filtrate to pass
from the blood into the glomerular capsule
The Nephron

Figure 25.4b
Connecting Tubules
Bagian distal portion dari distal tubulus convoluted yang
dekat ke collecting ducts
Connecting Tubules
Terdapat dua jenis sel penting, yaitu:
Intercalated cells

Sel-sel Kuboid dengan microvilli

Berfungsi pada maintain keseimbangan asam


basa tubuh
Principal cells

Sel-sel kuboid tanpa microvilli

Membantu maintain cairan tubuh dan


keseimbangan garam
Nephrons
Cortical nephrons 85% of nephrons; lokasi pada
cortex

Juxtamedullary nephrons:
Berlokasi di cortex-medulla junction
Mempunyai loops of Henle yang menginvasi ke dalam
medulla
Mempunyai segmen yang ketebalan lebih extensive
Berperan dalam produksi konsentrasi urin
Nephrons

Figure 25.5b
Capillary Beds of the
Nephron
Every nephron has two capillary beds

Glomerulus
Peritubular capillaries

Each glomerulus is:

Fed by an afferent arteriole


Drained by an efferent arteriole
Capillary Beds of the
Nephron
Blood pressure in the glomerulus is high because:

Arterioles are high-resistance vessels


Afferent arterioles have larger diameters than efferent
arterioles

Fluids and solutes are forced out of the blood throughout


the entire length of the glomerulus
Capillary Beds

Figure 25.5a
Resistensi Vaskuler pd
Microcirculation

Afferent and efferent arterioles offer high resistance to


blood flow

Blood pressure declines from 95mm Hg in renal arteries


to 8 mm Hg in renal veins
Resistansi Vaskuler pd
Microcirculation
Resistance in afferent arterioles:
Protects glomeruli from fluctuations in systemic blood
pressure
Resistance in efferent arterioles:
Reinforces high glomerular pressure

Reduces hydrostatic pressure in peritubular

capillaries
Juxtaglomerular
Apparatus (JGA)
Where the distal tubule lies against the afferent
(sometimes efferent) arteriole

Arteriole walls have juxtaglomerular (JG) cells


Enlarged, smooth muscle cells

Have secretory granules containing renin

Act as mechanoreceptors
Juxtaglomerular
Apparatus (JGA)
Macula densa
Tall, closely packed distal tubule cells

Lie adjacent to JG cells

Function as chemoreceptors or osmoreceptors

Mesanglial cells:
Have phagocytic and contractile properties

Influence capillary filtration


Juxtaglomerular Apparatus (JGA)

Figure 25.6
Filtration Membrane
Filter that lies between the blood and the interior of the
glomerular capsule

It is composed of three layers


Fenestrated endothelium of the glomerular capillaries

Visceral membrane of the glomerular capsule


(podocytes)
Basement membrane composed of fused basal
laminae of the other layers
Filtration Membrane

Figure 25.7a
Filtration Membrane

Figure 25.7c
Mechanisms of Urine
Formation
The kidneys filter the bodys entire plasma volume 60
times each day

The filtrate:
Contains all plasma components except protein
Loses water, nutrients, and essential ions to become
urine

The urine contains metabolic wastes and unneeded


substances
Mechanisms of Urine Formation

Urine formation and


adjustment of blood
composition
involves three
major processes
Glomerular
filtration
Tubular
reabsorption
Secretion

Figure 25.8
Glomerular Filtration
Principles of fluid dynamics that account for tissue fluid in
all capillary beds apply to the glomerulus as well
The glomerulus is more efficient than other capillary
beds because:
Its filtration membrane is significantly more permeable

Glomerular blood pressure is higher


It has a higher net filtration pressure
Plasma proteins are not filtered and are used to maintain
oncotic pressure of the blood
Net Filtration Pressure
(NFP)
The pressure responsible for filtrate formation

NFP equals the glomerular hydrostatic pressure (HPg)


minus the oncotic pressure of glomerular blood (OPg)
combined with the capsular hydrostatic pressure (HPc)

NFP = HPg (OPg + HPc)


Glomerular Filtration
Rate (GFR)
The total amount of filtrate formed per minute by the
kidneys

Factors governing filtration rate at the capillary bed are:


Total surface area available for filtration

Filtration membrane permeability

Net filtration pressure


Glomerular Filtration
Rate (GFR)
GFR is directly proportional to the NFP

Changes in GFR normally result from changes in


glomerular blood pressure
Glomerular Filtration
Rate (GFR)

Figure 25.9
Regulation of Glomerular
Filtration
If the GFR is too high:

Needed substances cannot be reabsorbed quickly


enough and are lost in the urine

If the GFR is too low:


Everything is reabsorbed, including wastes that are
normally disposed of
Regulation of Glomerular
Filtration
Three mechanisms control the GFR

Renal autoregulation (intrinsic system)


Neural controls
Hormonal mechanism (the renin-angiotensin system)
Intrinsic Controls
Under normal conditions, renal autoregulation maintains
a nearly constant glomerular filtration rate

Autoregulation entails two types of control


Myogenic responds to changes in pressure in the
renal blood vessels
Flow-dependent tubuloglomerular feedback senses
changes in the juxtaglomerular apparatus
Extrinsic Controls

When the sympathetic nervous system is at rest:


Renal blood vessels are maximally dilated

Autoregulation mechanisms prevail


Extrinsic Controls
Under stress:
Norepinephrine is released by the sympathetic
nervous system
Epinephrine is released by the adrenal medulla
Afferent arterioles constrict and filtration is inhibited
The sympathetic nervous system also stimulates the
renin-angiotensin mechanism
Renin-Angiotensin
Mechanism
Is triggered when the JG cells release renin
Renin acts on angiotensinogen to release angiotensin I
Angiotensin I is converted to angiotensin II
Angiotensin II:
Causes mean arterial pressure to rise

Stimulates the adrenal cortex to release aldosterone

As a result, both systemic and glomerular hydrostatic


pressure rise
Renin Release
Renin release is triggered by:
Reduced stretch of the granular JG cells

Stimulation of the JG cells by activated macula densa


cells
Direct stimulation of the JG cells via 1-adrenergic
receptors by renal nerves
Angiotensin II
Renin Release

Figure 25.10
LFG/GFR

LFG/GFR adalah mengukur berapa banyak filtrat yang


dihasilkan oleh glomerulus
Merupakan pengukuran paling baik untuk menilai fungsi
eksresi
Filtrasi dipengaruhi oleh aliran plasma , perbedaan
tekanan, luas permukaan kapiler, dan permeabilitas
kapiler
LFG merupakan jumlah dari hasil semua nefron (rata-
rata 1 juta tiap ginjal)
Blood supply to the kidney:

Renal arteries from abdominal aorta enter hilum and branch:

1. Interlobar arteries - pass through renal columns and reach junction


between medulla and cortex

2. Arcuate arteries run parallel with the base of the pyramids

3. Interlobular arteries move up into the cortex and branch to form the
afferent arteriole

The peritubular capillaries unite to form the interlobular veins, arcuate vein,
interlobar vein, renal vein

The renal vein exits at hilus and joins the IVC


Nephron
= Functional unit of the kidney, ~ 1 million nephrons per kidney!

Tubular components:
1. Glomerular (Bowmans) capsule double-walled cup
simple squamous epithelium

2. Proximal convoluted tubule - coiled 1st section


simple cuboidal epithelium with microvilli

3. Loop of Henle - hair-pin loop


thin descending limb, thick ascending limb

4. Distal convoluted tubule - last section


simple cuboidal epithelium
specialised region - Juxta glomerular apparatus

Distal convoluted tubule opens into the collecting system


collecting ducts papillary ducts minor calyx
Internal anatomy

ureter enters renal sinus, it


expands to form a chamber
called - renal pelvis

pelvis branches to form 2-3


major calyces
branch further to form 6-8
minor calyces
Each minor calyx surrounds
the papilla of a renal pyramid

ducts within papilla connect to


wall of the calyx and discharge
urine produced in the cortex
and medulla

Urine passes through the


calyces into the ureter
Internal anatomy

outer cortex, inner medulla

6-18 conical renal pyramids

apex - renal papilla projects


into the renal sinus

renal columns
extend from cortex inward to
renal sinus between
adjacent renal pyramids

granular texture similar to


that of the cortex
Rumus Homer Smith untuk mengukur renal klirens :

C=UXV
P
C = Klirens
U = Konsentrasi zat marker dalam urin
V = Volume urin
P = Konsentrasi zat marker dalam plasma