The MultiExpertise of the Kidney

PT 515 Clarkson University Physical Therapy Program

Wilton Remigio, DSc

Learning Objectives
1. Describe the functional importance of the glomerulus 2. Explain the 3 basic processes of urine formation 3. Describe the control of BP and Water balance 4. Explain renal handling of the major electrolytes, organic and inorganic substances

Pathology/Epidemiology
How many patients with kidney disease? 23 million adults age 20 and above Whats the incidence? 111,000 cases What are the main causes? Diabetes, hypertension, glomerulonephritis, and polycystic kidney disease are the leading causes of ESRD. ESRD due to diabetes is increasing at an annual rate of more than 11% per year. How many have had kidney transplant? In 2007 17,000 How many are waiting for a transplant? >54,000 patients are awaiting for a donnor

Recognizing Kidney Disease

Common signs and complains

Change in frequency and quantity of urine passed, especially at night (usually increase at first) Blood in the urine (haematuria) Foaming urine Puffiness around the eyes and ankles (oedema) Pain in the back (under the lower ribs, where the kidneys are located) Pain or burning when passing urine.

Symptoms
Tiredness, inability to concentrate Generally feeling unwell Loss of appetite Nausea and vomiting Shortness of breath

Lifestyle changes
Eat lots of fruit and vegetables including legumes (peas or beans) and grain-based food like bread, pasta, noodles and rice. Eat only small amounts of salty or fatty food. Drink plenty of water instead of other drinks. Maintain a healthy weight. Exercise regularly. Dont smoke. Alcohol has a profound negative effect in eletrolyte, fluid balance and acidbase balance Have your blood pressure checked regularly. Do things that help you relax and reduce your stress levels. A low protein diet can treat & prevent some kidney conditions and postpone dialysis Avoid toxic substances and stress to kidney (post exercise nephritis)

Renal Multitasking
Regulation of Water and Electrolyte Balance of body fluids (extracellular) Excretion of Metabolic Waste Excretion of bioactive substances ( hormones , foreign substances, specifically drugs affecting body function) Regulation of Arterial Blood pressure Regulation of Red Blood cell production Regulation of Vitamin D production Gluconeogenesis

Urine formation glossary

Filtration Blood pressure
Water and solutes across glomerular capillaries

Reabsorption
The removal of water and solutes from the filtrate

Secretion
Transport of solutes from the peritubular fluid into the tubular fluid

Excretion = urine

Kidney topography

Topography

cont

Normal Radiographic Anatomy

Kidney Topography cont

The collection of filtrate (urine)

Name the structures

The Kidney

Kidney Perfusion

Complete Nephron

Cortical and Juxtamedullary Nephrons

Urine formation
Filtration
Blood pressure Water and solutes across glomerular capillaries

Reabsorption
The removal of water and solutes from the filtrate

Secretion
Transport of solutes from the peritubular fluid into the tubular fluid

Excretion = urine

FILTRATION

THE FILTER

Functional Unit

Afferent and Efferent (hot and cold)

Filtration

Glomerular Seive

Filtration

Filtration

Filtration Fraction

Filtration basics
Proximal Tubule Absorbs 65% of filtered water , Na+, Cl- and K+. 100% of filtered glucose, AA and small peptides is absorbed. Proximal tubule cell secrete acids and bases (HCO3). This secretion is a major route for drugs such as penicillin.

Glomerular Filtration Rate (GFR)

Arteriolar resistance determines filtration rate. GFR has to do with how much filtrate is running down the tubules per unit of time Fast filtrate will change reabsorption dymanics of solutes present in filtrate GFR is used to find how substances are cleared from the blood (meds) Kidney disfunction -Filtration problems go from mild to renal failure (need for dyalisis)

Glomerular Filtration activity

Renal Blood flow Afferent constriction Efferent Constriction Afferent dilation Efferent dilation Glomerular capillary pressure Glomerular filtration rate Peritubular capillary Pressure Peritubular Reabsorption

REABSORPTION
Proximal Tubule Thin loop Distal tubules Collecting Duct

Reabsorpsion + secretion
Reabsorption : A two step process
1. 2.

Reabsorption of water and most particles dissolved (solutes) are linked to the absorption of Na

Proximal Tubule-Reabsorption
Microscopic Anatomy

Basis for Peritubular Reabsorption

Peritubular capillaries provide nutrients for tubules and retrieve the fluid the tubules reabsorb. Oncotic P is greater than hydrostatic P in these capillaries, so therefore get reabsorption NOT filtration. Must occur since we filter 180l/day, but only excrete 1-2l/day of urine. Reabsorb 99% H2O, 100% glucose, 99.5% Na+ and 50% urea. Most of this occurs at proximal convoluted tubule.

Tubular Segments

Reabsorption
Why dont you urinate the same amount of water you drink? What creates the transition between filtration to Reabsorption ? If a substance is not reabsorbed what happens to it? What does secreted mean?

Resorption Thin Descending loop

Countercurrent Multiplier
The critical characteristics which create the countercurrent multiplier: 1. The ascending limb of the loop of Henle actively transports Na+ and cotransports Cl- ions out of the lumen into the interstitium. 2. The ascending limb is impermeable to H2O. 3. The descending limb is freely permeable to H2O but relatively impermeable to NaCl. 4. H2O that moves out of tubule into intersitium is removed by the blood vessels called vasa recta thus gradients are maintained and H2O is returned to the circulation.
D A

Na

X X

Na
H2O

H2O

Countercurrent Multiplier
A: The tubule is initially filled with isotonic fluid B: Na is pumped out of the ascending loop, raising the osmotic pressure outside and lowering it inside. Note that the maximum gradient (inside to out) is 200 mosm/L C: Water flows out of the descending tubule by osmosis, raising the osmotic pressure in the descending tubule to 400 mosm/L D: Fresh fluid enters from the glomerulus, pushing concentrated fluid (400 mosm/L) into the ascending limb E: In the 2nd round the Na pump produces another 200 mosm/L gradient across the membrane, but it is starting from a more concentrated solution, so the external osmolarity rises to 500 mosm/L. F: The 3rd round of Na pumping raises interstitial concentration to 700 mosm/L, and so on.
The pumping, osmotic flow and filtration flows are shown as separate activities, but in reality they occur together as a continuous process.

formation of hyperosmotic urine

Role of urea in concentrating urine

Urea very useful in concentrating urine. High protein diet = more urea = more concentrated urine. Kidneys filter, reabsorb and secrete urea. Urea excretion rises with increasing urinary flow.

Urea recycling
Urea toxic at high levels, but can be useful in small amounts. Urea recycling causes buildup of high [urea] in inner medulla. This helps create the osmotic gradient at loop of Henle so H2O can be reabsorbed.

Juxta Glomerulus Apparatus

Resorption- Collecting Tubules

Summary

Kidney Function Overview

Peritubular capillaries Efferent arteriole Glomerulus F R Bowmans capsule Proximal tubule R S R Loop of Henle Collecting duct E E = Excretion: lumen to external environment To bladder and external environment To renal vein R S R Distal tubule S

Afferent arteriole

KEY F R S = Filtration: blood to lumen = Reabsorption: lumen to blood = Secretion: blood to lumen

Histology

Review Blood volume and Pressure

Studies cited
Clin Nephrol. 1998 Nov;50(5):273-83. Effect of a ketoacid-aminoacid-supplemented very low protein diet on the progression of advanced renal disease: a reanalysis of the MDRD feasibility study. Teschan PE, Beck GJ, Dwyer JT, Greene T, Klahr S, Levy AS, Mitch WE, Snetselaar LG, Steinman TI, Walser M. Vanderbilt University, USA. J Am Soc Nephrol. 1999 Jan;10(1):110-6. Can renal replacement be deferred by a supplemented very low protein diet? Walser M, Hill S. J Nephrol. 2001 Nov-Dec;14(6):433-9. Low protein diets and outcome of renal patients. Aparicio M, Chauveau P, Combe C.