RENAL PHYSIOLOGY

Zekeriyya ALANOGLU, MD., DESA

Ahmet Onat Bermede, MD., DESA
Ankara University School of Medicine
Dept. Anesthesiology and ICM
www.esahq.org
www.esahq.org
www.esahq.org
www.esahq.org
www.esahq.org
Kidneys
• Stabilize the composition of the ECF (electrolyte, H+
concentration)
• Excrete end-products of protein metabolism (urea)
• Retain essential body nutrients (amino acids, glucose)
• Secrete hormones
• Regulation of sistemic blood pressure (angiotensin II, PG,
kinins)
• Production of erythrocytes (erythropoietin)

www.esahq.org
Anatomy

• 115 – 160 g
• Located retroperitoneally, beneath the diaphragm
• Cortical (outer) and medullary (inner) portion
• Level of L2
• Receives 20% of the CO

www.esahq.org
Nephron

www.esahq.org
 Nephron
• Glomerulus
• Only in renal cortex
• Invaginate into dilated blind end of
renal tubule as Bowman’s capsule
• Afferent arteriol→ Efferent arteriol

Afferent Efferent
Arteriole Arteriole

Proximal
Tubule
10 www.esahq.org
 Nephron
• Renal tubule
• Proximal con. tubule → Loop
of Henle → Distal con. tubule
• Cortical ve Juxtamedullary
nephrons
• Collecting duct delivers fluid
into the renal pelvis
• Water and solutes are
reabsorbed
• Other solutes are secreted by
epithelial cells

www.esahq.org
Renal Blood Flow

• Receives 20-25% of cardiac output

• 400 mL/100 g/min (Heart and liver 70 mL/100 g/min)
• 90-95% of blood flow delivered to the renal cortex
• High oxygen consumption
• Renal cortex PO2 50mmHg; 10 mmHg in medulla

www.esahq.org
Influence of Anesthesia and Surgery

• Anesthetic drugs
• Potential to alter renal function (systemic blood pressure, CO)
• Redistribution of blood flow
• Renal cortex  Inner renal medulla
• Sodium and water conservation
• Anesthetic-induced
• Decreases in CO
• Release of arginine vasopressin (AVP) (ADH)
• Increased activity of sympathetic nervous system
• Renin angiotensin aldosterone system

www.esahq.org
Influence of Anesthesia and Surgery
• Hypovolemia + sympathethic nervous system
• ↑ Renal vascular resistance
• ↑ Shunt to non renal sites

!!! Intraoperative urine output does not correlate with

postoperative renal function.

www.esahq.org
Prostaglandins
• Renal response to ischemia

• NSAID
• Inhibits COX
• No effect in healthy subjects
• RBF ↓ and GF ↓ if renal circulation compromised

• PGE2, ↓ Na+ reabsorption  ↓ O2 consump.

www.esahq.org
 Glomerular capillaries

• Afferent arteriole
• Efferent arteriole→
Resistance to blood flow
• Glomerular capillaries
→High pressure system
• Fluid moving into Bowman’s
capsule

www.esahq.org
 Peritubular capillaries
• Renal cortex blood flow
• Efferent arteriole → Peritubular
capillaries
• Low pressure system
• Fluid from renal tubules is
absorbed
• 180 L/day filtered from
glomerular capillaries
1.5-2 L stays in the renal tubules

www.esahq.org
 Vasa Recta

• Renal medulla blood flow

• Maintain a high osmolarity
• Solute transport out of the
ascending limb of Henle
• Allow tubular fluid to be
concentrated
• Countercurrent arrangement
of a specialized portion of the
peritubular capillaries: Vasa
recta

www.esahq.org
Autoregulation of Renal Blood Flow
• MAP 60,80 - 160, 180
mmHg

• Myogenic response
• Increased Wall tension in aff.
art.
• Tubuloglomerular feedback
• Increased filtration may lead
autoregulation
• General Anesthesia
• Sepsis
www.esahq.org
Juxtaglomerular Apparatus

www.esahq.org
Juxtaglomerular Apparatus
• Distal renal tubule passes in the angle between
afferent and efferent arteriole

• Renin

www.esahq.org
Glomerular Filtrate

Great permeability of glomerular capillaries

Presence pores in the endothelial cells

Rapid filtration of fluid and small molecular weight

substance (<8 nm)

Glomerular filtrate: Plasma without proteins

www.esahq.org
Glomerular filtration rate
• The amount of glomerular filtrate (GF) formed each
minute by all the nephrons.

• 125 mL/min, 180 L/day

• Reabsorption %99 of GF during passage through renal

tubule

• Urinary sodium ion excretion parallels GFR

www.esahq.org
Glomerular Filtrate

• Normal GFR 12.5 mL/min/mmHg of filtration pressure

resulting in a GFR of 125 mL/min
• Net filtration pressure 10 mmHg

www.esahq.org
Glomerular Filtrate
• Mean arterial pressure
• Blunted by autoregulation
• Tubuloglomerular feedback
• Cardiac output
• Sempathetic nervous system
• T4-T12
• Preferential constriction of afferent arteriole
• Glomerular blood flow ↓

www.esahq.org
 Renal Tubular Function

• Reabsorption is more important than secretion (K+ and H+)

• 2/3 of reabsorption and secretion is in proximal renal
tubules
• Major determinants
• Aldosteron
• AVP
• Renal prostaglandins
• ANF

www.esahq.org
Renal Tubular Function
• Active transport against concentration gradient
• Na-K ATPase system
• Cotransport (glucose, amino acid, organic acid)
• Proximal convoluted renal tubules 80% O2 consumption

• Aldosteron → Reabsorbtion of Na, secretion of H

and K in the distal tubule

www.esahq.org
Renal Tubular Function
• 99% of water reabsorbed
• Distal renal tubules impermeable to water
• Important for controlling the specific gravity of urine…
• AVP (ADH)→ determines permeability of epithelial
cells in collecting ducts

www.esahq.org
Renal Tubular Function
• Aquaporins
• Simple diffusion protein water channel
• Aquaporin – 1, 2, 3 in kidney
A-4 in brain
A-5 in salivary glands and respiratory tract

• Countercurrent system
• High osmolarity renal MEDULLA interstitial fluid
• Blood inflow runs parallel and opposite direction to outflow
• Eliminate soluts with minimal excretion of water

www.esahq.org
Regulation of Body Fluid

• Blood volume
• Extracellular fluid volume
• Osmolarity of body fluids
• Plasma concentration of ions

www.esahq.org
Blood Volume

www.esahq.org
Extracellular Fluid Volume

• Same as blood volume

• Reservoir for excess fluid that may be administered

intravenously during perioperative period

www.esahq.org
Osmolarity of Body Fluids

• Concentration of sodium in extracellular fluid

• Osmoreceptor-AVP mechanism
• Thirst reflex

• Aldosterone effect is limited!!!

www.esahq.org
Osmolarity of Body Fluids
• Osmoreceptor-AVP mechanism
• Increased osmolarity of extracellular fluid
• Supraoptic nuclei of hypothalamus
• AVP release from posterior pituitary
• Retention of water

• Thirst reflex
• Increased Na+ concentration in ECF causes
• Angiotensin II production
• Sensation of dry mouth
• Na + ↑ 2mEq/L or plasma osm ↑ 4 mOsm/L

www.esahq.org
Plasma Concentration of Ions
• Potassium

• Aldosteron effects on renal tubules

• Increased secretion of K + ions

• H+ ions compete for secretion

• Na+ intake may influence potassium

www.esahq.org
Plasma Concentration of Ions
• Sodium
• Active transport of Na+ into peritubular capillaries
• 2/3 of Na + reabsorbed from proximal tubules

• Aldosterone
• Influences Na reabsorption from distal tubules and
collecting ducts

www.esahq.org
Plasma Concentration of Ions
• Hydrogen
• Secrete H+ by exchanging Na +
• Acidify the urine
• Ammonium formation

• Calcium
• Parathyroid hormone

• Magnesium
• Reabsorbed by renal tubules

www.esahq.org
 Plasma Concentration of Ions
• Urea

• Most abundant of the metabolic waste products

• Determining the rate of urea excretion

• Blood urea nitrogen (BUN)
• GFR

• 50% of urea enters the renal tubules appears in urine

www.esahq.org
Atrial – Renal Natriuretic Factors
• ANP;
• Synthesize by cardiac atria
• Related to atrial pressure and atrial diameter
• Cardiovascular regulator
• Vasodilator, ↓ systemic blood pressure
• Inhibition of ANP, ↓ urine output, Na + excretion and ↑ renin
• PEEP, ANP↓
• RNP (urodilatin);
• Synthesize by cortical nephrons
• Intrarenal regulation of Na excretion

www.esahq.org
Acute Renal Failure
Abrupt deterioration of renal function with a decrease
in glomerular filtration rate occuring over a period of
hours to days, resulting in the failure of kidneys to
excrete nitrogenous waste products (urea/cre) and to
maintain fluid and electrolyte homeostasis

www.esahq.org
Acute Renal Failure

www.esahq.org
Prerenal Azotemia
• Renal hypoperfusion

• Hypovolemia and renal artery atherosclerosis in

elderly patients

• NSAID in prostaglandin dependent patient for renal

vasodilatation

• Congestive heart failure, septic shock, radiocontrast

media

www.esahq.org
Intrinsic Renal Failure
• Renal tubular necrosis due to ischemia or
nephrotoxins

• Destruction of epithelial cells lining the renal tubules

• Imbalance of the oxygen supply and demand of renal

medullary ascending limb tubular cells

• Ischemia of renal medullary ascending tubular cells in

the perioperative period

www.esahq.org
Postrenal Nephropathy
• Obstructive renal failure
• Renal stones
• Prostatic hypertrophy
• Mechanical kinking of catheters

• Sudden acute oliguria in perioperative period

• Mechanical obstruction of drainage devices

www.esahq.org
Acute Renal Failure
• Oliguric
• Urine output < 400 mL/day

• Nonoliguric
• Urine output > 400 mL/day
• Better prognosis

• 20-60% of patients require dialysis

www.esahq.org
Acute Renal Failure
• Diagnosis

www.esahq.org
Acute Renal Failure
• Treatment
• Reverse underlying cause
• Correct fluid and electrolyte imbalances
• Dopamine if needed
• Mannitol and furosemid ?
• Dialysis
• Volume overload
• Hyperkalemia
• Metabolic acidosis
• Severe uremia

www.esahq.org
Chronic Renal Failure
• Progressive loss of nephron function and decline in GFR

www.esahq.org
Chronic Renal Failure
• Manifestations of chronic renal failure

• Accumulation of metabolic waste products in blood

• Excretion of fixed specific gravity urine
• Metabolic acidosis
• Hyperkalemia
• Anemia
• Platelet dysfunction
• Fluid overload and systemic hypertension
• Nervous system dysfunction
• Osteomalacia

www.esahq.org
Chronic Renal Failure

• Dialytic Therapy

• Indications
• Hyperkalemia
• Acidosis
• Fluid overload
• BUN 80-100 mg/dL

• Infection remains main cause of death

• Intermittent, continuous and peritoneal

www.esahq.org
Chronic Renal Failure
• Complications of Dialytic Therapy

• Infection
• Activation of complement system
• Hypotension
• Arterial hypoxemia
• Skeletal muscle cramping
• Protein depletion
• Anticoagulation
• Access failure

www.esahq.org
www.esahq.org
www.esahq.org
www.esahq.org
Title area
First Name Last Name
Department
Hospital, Country
Conflict of interest declaration
WHAT DECLARATION
Grants/research support/P.I.
Employee
Consultation fees
Honoraria
Speakers bureau
Company sponsored
Stock shareholder
Spouse/partner
Scientific Advisory Board
Other

www.esahq.org
Slide Title

• Please use this slide layout for the content.

www.esahq.org
www.esahq.org