RENAL GOLMERULAR

DISORDERS
RENAL TUBULAR
DISORDERS.
RENAL STONE
KIDNEY FUNCTIONS
 Urine formation.
 Fluid and electrolyte balance.
 Regulation of acid-base balance.
 Excretion of the waste products of protein metabolism.
 Excretion of drugs and toxins.
 Secretion of hormones
Renin
Erythropoietin
1,25-Dihydroxy vitamin D3
Prostaglandins
 RENAL PHYSIOLOGY
There are three basic renal processes:
1. Glomerular filtration
2. Tubular reabsorption
3. Tubular secretion

kidney function tests are used in assessment of

renal disease, water balance, and acid-base
Glomerular Filtration
The glomerulus is the first part of the nephron and
functions to filter incoming blood.
water, electrolytes, and small dissolved solutes,
such as glucose, amino acids, low-molecular-
weight proteins, urea, and creatinine, pass freely
through the basement membrane and enter the
proximal convoluted tubule.
Other blood constituents, such as albumin; many
plasma proteins; and protein-bound substances,
such as lipids and bilirubin, are too large to be
filtered.
The volume of blood filtered per minute is the
glomerular filtration rate (GFR), and its
determination is essential in evaluating renal
function
Tubular Function
The proximal tubule is the next part of the nephron to
receive the now cell-free and essentially protein-free
blood.
This filtrate contains waste products, which are toxic
to the body above a certain concentration, and
substances that are valuable to the body.
One function of the proximal tubule is to return the
bulk of each valuable substance back to the blood
circulation.
Thus, 75% of the water, sodium, and chloride;
100% of the glucose (up to the renal threshold );
almost all of the amino acids, vitamins, and
proteins; and varying amounts of urea, uric acid,
and ions, such as magnesium, calcium,
potassium, and bicarbonate, are reabsorbed.
Almost all (98%–100%) of uric acid, a waste product, is
actively reabsorbed, only to be secreted at the distal
end of the proximal tubule.
When the substances move from the tubular lumen to
the peritubular capillary plasma, the process is called
tubular reabsorption .
When the concentration of the filtered sub-stance
exceeds the capacity of the transport system, the
substance is then excreted in the urine.
The plasma concentration above which the substance
appears in urine is known as the renal threshold, and
its determination is useful in assessing both tubular
function and nonrenal disease states. A renal
threshold does not exist for water because it is always
transported passively through diffu-sion down a
concentration gradient.
Glomerular Diseases
Glomerular disease reduces the ability of the kidneys to
maintain a balance of certain substances in bloodstream.
Normally, the kidneys should filter toxins out of the
bloodstream and excrete them in the urine, but should keep
red blood cells and protein in the bloodstream.
In people with glomerular disease, red blood cells and
protein may be excreted into the urine, while toxins may be
retained.
Glomerular disease can develop suddenly
(called acute), or develop slowly over a period of
years (called chronic).
Sometimes a glomerular disease also interferes
with the clearance of waste products by the
kidney, so they begin to build up in the blood.
Furthermore, loss of blood proteins like albumin in the urine
can result in a fall in their level in the bloodstream.
In normal blood, albumin drawing extra fluid from the body
into the bloodstream, where it remains until the kidneys
remove it. But when albumin leaks into the urine, the blood
loses its capacity to absorb extra fluid from the body.
Fluid can accumulate outside the circulatory system in the
face, hands, feet, or ankles and cause swelling.
Acute Glomerulonephritis
Abnormal laboratory findings usually include:
 Hematuria.
 Proteinuria (usually albumin, and generally 3 g/day).
 Decreased GFR.
 Anemia.
Elevated blood urea nitrogen & serum creatinine
 oliguria.
sodium and water retention (with consequent hypertension
and some localized edema),
GLOMERULAR DISEASE DIAGNOSIS
Glomerular disease is diagnosed based upon blood or urine
tests. Other tests, including imaging tests and/or a kidney
biopsy, may be used to help diagnose the specific type of
glomerular disease.
Urine tests — The urinalysis may show:
 Red blood cells (which are seen when there is damage or
inflammation in the glomeruli).
 white blood cells (which can indicate inflammation), or
increased protein levels (which is an indicator of glomerular
damage).
Blood tests — Blood tests are used to measure the level of creatinine and
blood urea nitrogen (BUN), which become elevated when the kidneys are
damaged and are not filtering properly.

Imaging tests — An ultrasound of the kidney is frequently recommended if

glomerular disease is suspected, primarily to rule out other causes of blood
in the urine and/or decreased kidney function. The ultrasound can also
measure the size of the kidneys.
Kidney biopsy — A kidney (renal) biopsy may be needed to definitively
determine the cause of glomerular disease in patients that cannot be
diagnosed by blood tests or imaging tests alone.
Tubular Diseases
decreased excretion/reabsorption of certain
substances or reduced urinary concentrating
capability. Clinically, the most important defect
is renal tubular acidosis (RTA), the primary tubular
disorder affecting acid-base balance. This disease can
be classified into two types, depending on the nature
of the tubular defect:
■ Distal RTA, in which the renal tubules are unable to keep
up the vital pH gradient between the blood and tubular fluid
■ Proximal RTA, in which there is decreased bicarbonate
reabsorption, resulting in acidosis.
In general, reduced reabsorption in the proximal tubule
is manifested by findings of abnormally low serum
values for phosphorus and uric acid and by glucose and
amino acids in the urine. In addition, there may be some
proteinuria (usually 2 g/day).
kidney stones
kidney stones, are formed by the combination of various
crystallized substances, these, calcium oxalate stones are by far
the most commonly encountered.

result of several causes but mainly a reduced urine flow rate

(related to a decreased fluid intake) and saturation of the urine
with large amounts of essentially insoluble substances.
stones is important in determining the cause of the
condition.
Clinical symptoms are, of course:
hematuria, urinary tract infections,
TYPES OF KIDNEY STONES

Calcium oxalate
Hyperparathyroidism
High urine calcium
Vitamin D toxicity
Osteoporosis

Magnesium ammonium phosphate

Infectious processes

Calcium phosphate
Excess alkali consumption
Infection with urease producing organisms

Uric acid
Gout
High levels of uric acid in blood and urine
Renal Failure
Assessment of Renal Function
Glomerular Filtration Rate (GFR)
= the volume of water filtered from the plasma per unit of time.
Gives a rough measure of the number of functioning nephrons
Normal GFR:
Men: 130 mL/min./1.73m2
Women: 120 mL/min./1.73m2
Cannot be measured directly, so we use creatinine and creatinine
clearance to estimate..

 normal results range from 90 to 120 mL/min/1.73 m2.

Older people will have lower than normal GFR levels,
becauseGFR decreases with age. Normal value ranges may vary slightly
among different laboratories.
Stages of Chronic Kidney Disease
Stage Description GFR (mL/min/1.73 m2)
1 Kidney damage with normal or ≥ 90
increased GFR
2 Kidney damage with mildly 60-89
decreased GFR
3 Moderately decreased GFR 30-59
4 Severely decreased GFR 15-29
5 Kidney Failure < 15
GFR is reported as a number.

A GFR of 60 or higher is in the normal range.

A GFR below 60 may mean you have kidney disease.
A GFR of 15 or lower may mean kidney failure.
Assessment of Renal Function (cont.)
Creatinine
A naturally occurring amino acid, predominately found in skeletal
muscle
Freely filtered in the glomerulus, excreted by the kidney and readily
measured in the plasma
As plasma creatinine increases, the GFR exponentially decreases.
Limitations to estimate GFR:
Patients with decrease in muscle mass, liver disease, malnutrition,
advanced age, may have low/normal creatinine despite underlying
kidney disease
15-20% of creatinine in the bloodstream is not filtered in glomerulus,
but secreted by renal tubules (giving overestimation of GFR)
Medications may artificially elevate creatinine:
Trimethroprim (Bactrim)
Cimetidine
Assessment of Renal Function (cont.)
Creatinine Clearance
Best way to estimate GFR
GFR = (creatinine clearance) x (body surface area in m2/1.73)
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