Faal KBK Ginjal.ppt

7/30/2019 Faal KBK Ginjal.ppt

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The Kidney Function

ByM. Rasjad Indra

Retty RatnawatiEndang SriwahyuniEdwin Widodo


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Clinical Case:

A 10 year boy has some symptoms: dark red urine andswollen/puffy face. This patient also complains about pain duringswallowing, high fever and respiratory tract inflammation. Now, all

symptomps are relieved.

From physical analysis: increased blood pressure and edema on face

and foot.

From blood analysis: increased creatinin and urea and reducedplasma albumin. Also foundproteinuria and gross hematuria.


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Based on those anamneses and physical analysis, this patient is

suspected to sufferglumerulonephritis, a disease of immune system

with failure ofglumerulus. This disease is self-relieved, with loss

of signs and symptomps. Some patients can have worse outcome,

the diseases becomes persistent and develop as permanent renal

failure.These signs and symptoms are the effect of glumerolus function

failure leading to renal failure.

Human kidney plays important roles on maintainingvolume and

composition ofextracelluler fluid. This organ maintains internalbody environments. As a result, failure of structure and function of

this organ will dysharmonize humanbody homeostasis.


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Main function

Excretion of metabolic waste products &foreign chemicals

Regulation of: water & electrolyte balances.

body fluid osmolarity & electrolyteconcentration.

acid-base balance.

arterial pressure.

Secretion, metabolism, and excretion ofhormones

Gluconeogenesis


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Slide 6

Blood Clearance

Efective Efficient

What and how

much should beremoved

Space

Time

EnergyFiltration

Still needed

Unsufficient

Reabsorption Secretion

Pore Pressure

Na

K

Cl

HydrogenGlucose

Protein

Creatinine

Urea

Glomerulus

Tub. Proks.

Ansa Henle

Tub. distalis

Peritubular I

Vasa recta

Peritubular II

Difusion

Osmosis

Bioche

mistry

ExcretionSELESAI

Slide 11

Slide 16

Slide 28


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Renal Blood Flow (RBF)

1200 ml/minute or 20-25% of cardiac out put

Both kidney weigh: 300 gr or 0.5% b.w. Blood flow per grams of kidney tissue: 4 ml /

minute => 1200 ml / 300 gr, why?

Blood flow is highest in the renal cortex, why? RBF & GFR change relatively little if arterial blood

pressure between 80 - 180 mmHg, why?


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The nephron ~ Functional Unit

Each kidney contains about 1 million nephrons

The kidney cannot regenerate new nephrons.

After age 49 the number usually decrease 10 %

every 10 years.

Regional differences in nephron structure:

Cortical nephrons: they have short loops.

Juxtamedullary nephrons: they have long loops. Urine formation results from: Glumerular filtration,

tubular reabsorption, and tubular secretion.

Urinary excretion rate = Filtration rate- Reabsorption rate + Secretion rate


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Ke Counter Current


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Two capillary beds: The glomerular & Peritubularcapillaries

Are arranged in series

Separated by the efferent arterioles

Regulate the hydrostatic pressures in both sets of capillaries.

Hydrostatic pressure: The glomerular (high ~ 60 mmHg) => for filtration.

The peritubular (low ~ 13 mm Hg) => for reabsorption.

By adjusting the resistances of afferent and efferent arterioles

The kidneys regulate the hydrostatic pressure of the glomerular &

peritubular capilaries.

Changing the rate of filtration and / or tubular reabsorption.

Response to body homeostatic demands.

KEMBALI


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Urine formation start with the filtration of plasma inthe glomeruli:

Glomerular Filtration Rate (GFR) determined by: The balance of hydrostatic & colloid osmotic forces across the

glomerular membrane

The glomerular filtration coefficient (Kf)Net Filtr.Pressure= PG - PB - G+ B.

GFR= Kfx Net Filtration Pressure

Glomerular filtration is rather non selective: Protein are mostly retained in the plasma

Low-molecular weight substance are freely filtered(excepts that are bound to the plasma protein).

Negative charged large molecules are filtered less easilythan positively charged molecules of equal molecules size

Glomerular Filtration


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Macula densa

Juxtaglomerular cells


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Autoregulation of Glomerular Filtration Rate (GFR)& Renal Blood Flow (RBF)

Sympathetic activation decrease RBF & GFR Hormonal & Autocoid:

Norepinephrine, epinephrine & Endothelin decreasesRBF & GFR

Angiotensin II : Constricts Efferent arteriolincreasesGFR

Endothelial-derived Nitric Oxide (NO), Prostaglandin, &Bradykinin: increases RBF & GFR

Role of Tubuloglomerular Feedback: Macula densa (Sodium Chloride level in Macula Densa)

Renin-Angiotensin Efferent arteriolar resistance & Afferent arteriolar

resistance

Myogenic Autoregulation

High protein intake & High blood sugar => increase RBF& GFR


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Arterial Pressure

Glomerular hydrostatic

pressure

Macula Densa

Na Cl

Proximal Na Cl

reabsorption

Efferent Arteriolar

resistance

Afferent Arteriolar

resistance

Angiotensin II

Renin

GFR

KEMBALI
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Reabsorption & Secretion Tubular reabsorption includes Passive & Active

mechanism.1.Across the tubular epithelial cells into interstitiel

2.Through the peritubular capillary membrane back intothe blood

Active transport (against electrochemical gradient& requires energy.1.Primary active transport

Expl: Sodium transport in luminal membrane prox. Tub.

2.Secondary active reabsorption Expl.: Glucose & amino acid reabs.

Secondary active Secretion: Expl: Hydrogen ion: Counter-transport with sodium

reabsorption in luminal membrane


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Glucose:All of the filtered are activelyreabsorbed and sodium dependent.

Urea & Chloride arepassively reabsorb.

Active absorb. of Na+

--> the driving forcefor tubular reabsorb. of water, glucose,amino acids, chloride and phosphate.

Some organic compounds are secreted

from the blood into the tubular urine.


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Transport Maximum

Transport maximum for substances that are activelyreabsorbed:

Glucose 320 mg/min.

Phosphate 0.10 mM/min.

Sulfate 0.06 mM/min.

Amino acid 1.5 mM/min. Uric acid 15 mg/min.

Lactate 75 mg/min

Plasma protein 30 mg/min

Transport maximum for substances that are actively

secreted:

Creatinin 16 ng/min

Para-aminohipuric acid 80 ng/min


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Constituent Filtered Reabsorbed Excreted

Water 167.5 liters 166 liters 1.5 liters

Sodium 24,000 mmoles 23,900 mmoles 100 mmoles

Potasium 720 mmoles 630 mmoles 90 mmoles

Chloride 19,500 mmoles 19,400 mmoles 100 mmoles

Bicarbonate 4,500 mmoles 4,498 mmoles 2 mmolesPhosphate 6 g 5 g 1 g

Glucose 150 g 150 g 0 g

Urea 50 g 25 g 25 g

Uric acid 8 g 7.2 g 0.8 g

Creatinine** 1.5 g 0 g 1.8 g


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Reabsorption of glucose

Glucose is cotransport with sodiumacross the luminal cell membrane(uphill)

the energy from:

the sodium gradient, how?

the electrical gradient

Glucose leave the cell membrane to

peritubular capillary blood byfacilitated difussion


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Glucose Threshold

The ability to reabsorb is limited

At normal plasma glucose levels(65-90 mg/dl) => completely

reabsorb.

At 180-200 mg/dl => glucose firstappear in the urine (threshold).

Tubular transport maximum (Tm)for glucose: the maximal rate ofglucose reabsorption.


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Sodium (Na+):

Most filtered sodium is reabsorbed. The proximal tubules: 70%.

The loop of Henle: 20%

The distal tub. and collecting duct: 9%

The quantity of Na+ excreted =>importantrole in body sodium balance.


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CountercurrentMechanism

Loop of Henle (countercurrent multipliers)&Vasa recta (countercurrent ex-changers)

Loops of Henle: establish an osmotic gradientin the medulla.

The descending limb: water permeable

The ascending limb:

Active sodium transport

Low water permeability The vasa recta: remove water from the

medulla.

Ke Slide 9


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The collecting ducts:

Final regul. of Na+

excretion.Aldosterone andADH: increase Na+ and

water reabs. by the collecting duct.

Potasium (K+):

Filtered, reabsorb and secreted

The cortical collecting tubules:important site of K+ secretion.
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Ke Slide 5


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Clearance(CX)= UX x V (ml plasma/ minute) U: urine, V: Volume of urine

PX P: Plasma, x: substance

The Inulin clearance (CIN) = GFR .....Why ?

Endogenous Creatinine Clearance also = GFR ..... Why ?

Clearance Ratio = Cx

CInulin

PAH : para-amino hipuric acidPAH clearance (CPAH)=Effective Renal Plasma Flow (ERPF)

Renal Plasma Flow (RPF) = CPAH EPAH =PPAH-VPAH (Extraction Ratio)

EPAH PPAH

Renal Blood Flow (RBF) = RPF1-Hematocrit

Excretion Rate = Ux x V

Reabsorption Rate = Filtered Load Excretion Rate

= (GFR x Px) (Ux x V)

Secretion Rate = Excretion Rate Filtered Load

The Clearance Concept (CX) to Quantify Kidney Function


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Inulin:

Not be reabsorbed or secreted by the kidney

Not be metabolized, synthesized, or stored

Pass through the glomerular filtration

barrier unhindered

Nontoxic

Be able to measure in plasma and urine

Clearance Inulin ~ GFR (Glomerular Filtration rate)

Para-amino hipuric acid (PAH) is avidly secreted by tubules

that it is almost completely cleared from all of the plasma in

one passage of blood through the kidneys

Clearance PAH ~ ERPF (Effective Renal Plasma Flow)

uteplasmaml

plasmamlxmg

uteurineXmlurinemlxmgCx min/)(

)(/)(

min/)()(/)(


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Factor affecting urinaryconcentrating ability are:

Anti Diuretic Hormone

The length of Henles loop. Tubule fluid and blood flow

Urea.


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Urea Recirculation in RenalTubules


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The two ureters are muscular tubesthat carry the urine from the

kidneys to the bladder. The urinary blader functions as a

reservoir for urine and is

periodically emptied (micturition).

MICTURITION

A complex act involving autonomicand somatic nerves, spinal reflexes,and higher brain centers.


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Ke slide 5


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Kalium intake

Increase

[K+] plasmaEffect to

adrenal cortex

Increase

[K+] intracell

(including kidneyepithelial cell)

Secretion of aldosteron

Increase

Plasma aldosteron

Increase natrium pump / kalium in

tubulus distalis and ductus kolektivus

Increase

Kalium secretion

Increase

Kalium excretion

Normalkalium level

Kembali ke 26


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Reduce

Effective

Blood volume

Kidney

Angiotensinogen

Renin

Angiotensin I

Liver

Angiotensin II

Pembuluh darah Korteks Adrenal Hipotalamus

Vasokonstriksi Sekresi Aldosteron

Reabsorbsi NatriumBlood pressure > Reabsorbsi H2O

Sekresi ADH

Volume darah arterial efektif normal

Converting enzyme

Paru

Pusat Haus

Minum

Kembali ke 15


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Based on this data :


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Based on this data :

Konsentrasi inulin plasma = 0,3 mg / ml

Konsentrasi inulin urine = 6,0 mg / ml

Konsentrasi glukosa plasma = 4,0 mg / ml

Konsentrasi glukosa urine = 20,0 mg / ml

Konsentrasi PAH plasma = 0,02 mg / ml

Konsentrasi PAH urine = 2,4 mg / ml

Aliran urine rata-rata = 5 ml / minute

Hematokrit darah = 45 %

Answer these following questions :

Glomerular Filtration Rate (GFR) = ...........ml / minute

Clearance PAH = ml plasma / minute

Clearance glucose = ml plasma / minute

Glucose reabsorbsi rate = ...........mg / minute

Renal blood flow (RBF) = ..............l / minute

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