A.

Personal Data
Name: Mrs. Apple
Address: San Roque (Pob.), Paoay, Ilocos Norte
Hospital #: 300358
Sex: Female
Age: 27 y/o
Date of Birth: June 29, 1982
Place of Birth: San Roque,Paoay, Ilocos Norte
Civil Status: Married
Religion: Roman Catholic
Educational Attainment: Elementary Undergraduate
Occupation: Housewife
Chief Complaint: Dysuria; Flank pain
Admitting Diagnosis: Acute Pyelonephritis; CHF FC IC secondary to RHD MS MR
Admitting Physician: Dr. Lahoz; Dr. Urnos
Date and time of Admission: December 18, 2009 – 8:35 PM
Date and time of Discharge: December 23, 2009 – 1:50 PM
Attending Physician: Dr. Urnos; Dr. Lijauco
Principal Diagnosis: Acute pyelonephritis, resolved
ANATOMY AND PHYSIOLOGY

The urinary system consists of two

kidneys, two ureters, the urinary bladder, and
the urethra. A large volume of the blood flows
through the kidneys, which removes
substances from the blood to form urine. The
urine contains excess water and ions,
metabolic wastes such as urea, and toxic
substances consumed with food. The kidneys
also control the rate of RBC formation. As a
result, the kidneys play a major role in controlling the volume, ion concentration, pH, and RBC
concentration of the blood. The urine produced by the kidneys flows through the ureters to the
urinary bladder, where it is stored until it is eliminated through the urethra.

Different Parts of the Urinary System

A. KIDNEYS – reddish bean-shaped organs, each about the size of a tightly clenched fist located
retroperitoneal or posterior abdominal wall behind peritoneum to either side of the vertebral
column. The right kidney is slightly lower and the left kidney is slightly larger and longer. Each
kidney is approximately 11cm long x 7.5cm wide x 2.5cm thick and average weight in adult male
is 123-170 grams and 115-155grams in adult female.
There are three layers of tissues surrounding the kidneys, which includes; renal capsule
a smooth, transparent, fibrous connective tissue which encloses the kidney and serves as a
barrier against infection and trauma to the kidney; adipose capsule a mass of fatty tissue that
protects the kidney from blows and firmly holds the kidney in place; renal fascia is the
outermost layer which consists of a thin layer of fibrous connective tissue that also anchors the
kidney to the surrounding structures and to the abdominal wall.
External structures also include the Hilum/Hilus, a concave notch located at the medial
surface of each kidney where structures enter or leave the kidney through this notch such as
ureter, renal blood vessels, nerves, and lymphatic vessels. Another is the renal sinus which is a
cavity filled with fat (adipose tissue) and connective tissue into which the hilus opens.
Internal structures of the kidney is composed of the renal cortex, the outer portion of
the kidney which contains all of the glomeruli, most of the proximal tubules, and some
segments of the distal tubules. Next to it is the renal medulla which forms the inner part of the
kidney and consists of regions called renal pyramids (cone shape structures found in the
medulla of the kidney which extends into the renal pelvis and contains loops of Henle and
collecting ducts), the base of pyramids is called the renal papillae. Together, the cortex and the
renal pyramids make up the parenchyma of the kidney. Structurally, it consists of millions of
nephrons.
A funnel-shaped structures called renal calyx surrounds the tip of each pyramid.
Approximately, there can be 8 to 18 minor calyces minor calyces which collects urine from the
ducts of the pyramids. Minor calyces joins to form major calyces. There are 2 -3 major calyces
present in each kidney. Major calyces joins to form the renal pelvis, a large funnel shape
located in the renal sinus then narrows as it exits the hilum to become the ureter.
Microscopic structures includes parenchyma and composed of about 1.25 million
nephrons. Nephrons are the functional unit of the kidney and generally composed of the renal
corpuscles and renal tubules. The nephron begins as a double-walled globe known as
Bowman’s capsule. This is concave epithelial sac that surrounds the glomerulus and receives
the filtrate from the glomerular capillaries and located in the cortex of the kidney. The
innermost layer of the capsule is known as the visceral layer and consists of specialized
epithelial cells called podocytes. The outer wall of Bowman’s capsule is known as the parietal
layer. The visceral layer of podocytes surrounds a capillary network known as glomerulus.
These are tuft of capillaries supplied by afferent arteriole that filters blood and drained by the
efferent arteriole and normally does not allow large particles such as CHON’s and blood cells. A
group of specialized cells known as juxtaglomerular cells (rennin releasing cells) are located
around the afferent arteriole where it enters the renal corpuscle. Together, Bowman’s capsule
and glomerulus make up the renal corpuscle which is the first part of the nephron.
 Second part of the nephron is the tubular system which composed of proximal
convoluted tubule, loop of Henle, distal convoluted tubule and collecting tubule or ducts.
Proximal convuluted tubule is coiled tubule attached to the Bowman’s capsule which contains
thousands of microvilli and is the site of most reabsorption and first part of the renal tubule.
Next to it is the loop of Henle and is concern primarily with the transport of Na, Cl, and water.
There are 3 parts composed of the descending limb lined with squamous epithelial cells, thin,
without microvilli and extends to the medullary area; sharp turn, area where the descending
limb and ascending limb forms the U-shape of the loop; and the ascending limb, continuous to
distal convoluted tubule. There are kinds of nephrons according to location of Loop of Henle:
Juxtamedullary nephron, a nephron with a loop of Henle that dips deep into the medulla and
Cortical nephron, a nephron with loop of Henle that remains within the cortex and accounts to
85% of all nephrons. Distal convuluted tubule, a tube after the loop of Henle becomes
convoluted but has lesser amount of microvilli and the cells lining the tube called macula densa
(sodium-sensing cells of the distal tubule located between the afferent and efferent
arteriole ) contain numerous mitochondria that provide the energy for the active transport of
solute. The combination of juxtaglomerular cells and macula densa is called juxtaglomerular
apparatus that control renal blood flow, glomerular filtration and rennin secretion. Collecting
tubules is the last part of the renal tubule and is a large straight tubule where the distal tubule
merge to empty their contents. These tubules unite with each other in the medulla to form
renal papillary duct and consequently opens into a minor calyx to the renal pelvis. In the distal
and collecting tubule, principal cells reabsorb sodium and secrete potassium and intercalated
cells reabsorb potassium and bicarbonate and secrete H ions.

B. URETERS
Are two small tubes that drain urine from the renal pelvis to the urinary bladder which is
approx. 26-30 cm long lined with transitional epithelium and made up of muscular smooth
muscle bundles. They carry urine by peristalsis of the muscular wall but gravity and hydrostatic
pressure also contribute to the flow.
C. URINARY BLADDER
Is a hollow muscular organ located posterior to the symphysis pubis. Its wall is made of
smooth muscle tissue. It can hold 500 mL to 1000mL of urine and when urine reaches 200-
400mL, stretch receptors in the bladder initiate conscious desire to void and the unconscious
reflex called micturition reflex. The bladder contains 3 openings: 2 from ureters and 1 into the
urethra. Trigone is a triangular - shaped area outlined by the 3 openings and could accumulate
300-400 mL of urine before emptying. Detrusor muscle is muscle layer formed by a network of
crisscrossing bundles of smooth muscle fibers and it forms the bladder wall. The urine is also
controlled by two bladder sphincters includes the internal sphincter a smooth muscle of
bladder wall that is under involuntary control; and the external sphincter a skeletal muscle that
surrounds the urethra as it leaves the bladder and is under voluntary control.

D. URETHRA
Is a small thin-walled tube leading from the floor of the urinary bladder draining urine
outside of the body. Male urethra is approximately 20cm long extending common to both
urinary and reproductive organ. It carries urine out of the body and functions as passageway for
semen outside the body. Female urethra is located in the wall of vagina in an anterior position
above the vaginal opening. It is approximately measures 4 cm long.

The Functions of the Urinary System

1. Urine Formation
Urine formation begins when blood enters the afferent arteriole of the nephron and passes
through the capillary bed of the glomerulus. Filtration is the passage of liquid through a filtering
membrane as a result of the pressure of plasma forces. It is measured by glomerular filtration
rate and approximately 125mL/min (7.5L/hr) in average-sized adult. The various substances
normally filtered by the glomerulus, inside the tubules is the site for selective re-absorption of
these substances into the blood, this is also site for secretion of certain chemicals by active
transport from bloodstream, before being excreted in the urine.
Three Steps in Urine Formation includes:
a. Glomerular Filtration – refers to the movement of fluid across a semi-permeable
membrane by osmosis and diffusion in the renal corpuscles. The normal blood flow
through the kidneys is about 1,200mL/min. As blood flows into the glomerulus from an
afferent arteriole, glomerular filtration occurs. The filtered fluid, also known as
glomerular filtrate, which is composed of water, waste products, excess salts such as Na +
and K+, glucose, and other chemicals. Waste products such as urea should be eliminated
from the body. Urea is formed in the body to eliminate the very toxic ammonia products
that are formed in the liver from amino acids. This ammonia is converted to urea to be
excreted from the blood. The formation of filtrate depends on the filtration pressure
which is the pressure difference between the glomerular capillaries and Bowman’s
capsule.
b. Tubular Reabsorption – is the movement of substances out of the renal tubules back into
the blood capillaries located around the tubules. As the filtrate flows from Bowman’s
capsule to the proximal tubule, loop of Henle, distal tubule and collecting tubule, many
of the substances in the filtrate are reabsorbed. Of the 180 liters of filtrate each day,
99% is reabsorbed into the bloodstream, only 1% becomes the urine resulting in 1,000
to 1,500 of urine output each day. Most of the useful solutes that pass through the
filtration membrane into Bowman’s capsule are reabsorbed in the proximal convoluted
tubule. Filtrate volume is reduced by 65% in this side wherein water and solutes such as
proteins, amino acids, glucose, sodium and other substances are reabsorbed by active
transport. Another 15% is reabsorbed in the descending limb of loop of Henle which is
sodium chloride but little water is removed from the filtrate. The filtrate becomes
concentrated in the distal tubule and collecting ducts. Additional sodium chloride is
removed, water moves out by osmosis, and the filtrate volume is reduced by another
19%, leaving 1% of the original filtrate volume as urine.
c. Tubular Secretion – is the process by which substances move into the proximal, distal
and collecting tubules from blood in the capillaries around these tubules. Some
substances, including by-products of metabolism that become toxic in high
 concentrations and drugs or molecules not normally produced by the body are secreted
into the nephron from the peritubular capillaries. Tubular secretions can be active or
passive. Hydrogen ions are actively secreted in the proximal tubule. The epithelial cells
secrete large amount of H+ ions which plays an important role in the regulation of the
body fluid pH. Potassium ions are secreted in the distal tubule and collecting duct.
2. Electrolyte Balance
Electrolytes are filtered out in Bowman’s capsule only to be mostly resorbed in the proximal
tubules. Concentration is adjusted in the distal nephron under the influences of hormones such
as aldosterone and ADH. The regulation of fluids and electrolytes in the body occurs primarily
because of the feedback system between the nephrons and body fluids and tissues. The specific
mechanism for moving electrolytes across the tubular membranes are both passive and active,
this allows the kidney to maintain optimal electrolyte balance.
3. Maintenance of Acid-Base Balance
Plasma pH of arterial blood must be maintained between 7.35 to 7.45 for normal cell
function. It is achieved by maintaining a blood bicarbonate and carbon dioxide ratio of 20:1.
The respiratory system and kidneys work together. The lungs vary CO 2 content of the blood and
kidneys principally secrete or retain bicarbonate and hydrogen ions in response to the pH of the
blood.
4. Excretion of Metabolic Waste and Toxins
The kidney functions as the body’s main excretory organ. The major waste product of
protein metabolism is urea, which about 25 to 30g and excreted unchanged in urine. Other
waste products of metabolism are creatinine, phosphates and sulphates. The kidneys serve as
the primary mechanism for excreting drug metabolites which may be either directly or first
metabolized by the liver and then excreted by the kidneys.
5. Erythropoiesis
It is the red blood cell production. Decreased tissue oxygenation stimulates special cells in
the kidneys to produce erythropoietin. EPO stimulates the bone marrow to produce
proerythroblasts, which develop into erythrocytes thereby increasing the amount of Hgb
available to carry oxygen.
6. Blood Pressure Regulation
Blood pressure is manipulated through the kidney’s response to several mechanisms that
alter the total volume of blood in the circulatory system. These mechanisms includes ADH
response, the rennin-angiotensin system, and aldosterone response.
Anti-diuretic hormone (ADH) also known as vasopressin, is a hormone that is secreted by the
posterior part of the pituitary gland. It regulates water excretion and urine concentration in the
tubule by varying the amount of water that is reabsorbed. ADH affects the BP by increasing or
decreasing the amount of water to be reabsorbed.
The rennin-angiotensin system and aldosterone response also influence the regulation of
blood pressure. Rennin is a hormone released by the juxtaglomerular apparatus of the nephron
in response to sodium and potassium depletion, a drop in renal artery blood pressure, or
sympathetic stimulation. It stimulates the conversion of angiotensinogen to angiotensin I.
Conversion of angiotensin I to angiotensin II by angiotensin converting enzyme (ACE) from the
lungs, produces a powerful vasoconstriction and release of aldosterone. Aldosterone is released
from the adrenal glands and acts on the kidneys to resorb Na + and water, increasing circulating
blood volume and pressure.
7. Vitamin D synthesis
The kidneys influence the reciprocal calcium and phosphorus balance by converting the
inactive form of 1,25-dihydroxycholecalciferol. Vitamin D is necessary for maintaining normal
calcium and phosphorus balance in the body.
8. Micturition
It is also called as urination. It is a complex sensorimotor process which normally occurs
approximately 8 times in a 24-hour period. About 200 to 300 mL of urine can collect in the
bladder before the urge to void is felt. As the bladder wall is stretched, baroreceptor cause
reflex stimulation of parasympathetic nerves to the bladder, resulting in bladder contractions.
When motor nerves to the external urinary sphincter are inhibited, the muscle relaxes, opening
the sphincter and permitting urine to be expelled. The end products of ultrafiltration or urine
formation are finally eliminated in this last step, and homeostasis is maintained.
Blood Supply to the Kidney
The kidneys are highly vascular organs, receiving about 20% of the cardiac output in the
resting state, or about 1,200 mL/min. Arterial blood is supplied by the renal arteries, which
branch directly off the abdominal aorta.
The renal artery branches into approximately five segmental arteries, dividing the kidney
into vascular segments. The segmental arteries branch to form the lobar arteries that supply
each pyramid. The lobar arteries then branch several more times so blood can move
efficiently through each nephron. Each nephron has its own blood supply; blood enters the
glomerulus through the afferent arteriole and exits through the efferent arteriole. Blood
then flows through the peritubular arteries that surround the nephron’s tubules. Ultimately
the peritubular capillaries empty into venules that return the filtered blood to general
circulation via the renal venous system.