MINISTRY OF PUBLIC HEALTH OF UKRAINE
BUKOVINIAN STATE MEDICAL UNIVERSITY
Approval on methodological meeting
of the department of pathophisiology
Protocol №
Chief of department of the pathophysiology,
professor
Yu.Ye.Rohovyy
“___” ___________ 2008 year.
Methodological Instruction
to Practical Lesson
Мodule 2 : PATHOPHYSIOLOGY OF THE ORGANS AND SYSTEMS.
Contenting module 6. Pathophysiology of digestion, liver and kidney.
Theme 16: Pathophysiology of the kidney-1
Chernivtsi – 2008
1.Actuality of the theme. The renal failure depend to severe pathological
states. The disorder of constance of internal environment of organism, which one
thus arise, often demand emergency treatment. To the most often causes, which
one cause disturbance of functions of kidney, the disorder of their blood supply,
infections deseases, intoxication, autoallergy damages, violation of outflow of
urine concern. Knowledge of etiology and pathogenesis of kidney diseases,
mechanisms of disturbance, which one arise in renal failure, are necassary for
selection pathogenetic based methods of preventive maintenance and treatment.
2.Length of the employment – 2 hours.
3.Aim:
To khow: mechanisms by which altered filtration, reabsorbtion and
secretion of kidneys
To be able: to analyse of the increasing and decreasing the renal processes of
filtration, reabsorption.
To perform practical work: to analyse the mechanisms of the Acute Renal
Failure.
4. Basic level.
The name of the previous
disciplines
1.
histology
2.
biochemistry
3.
physiology
The receiving of the skills
Microscopical structure of kidney.
Role of kidney in maintenance of constance of an
internal environment.
Nervous and endocrine regulation
of kidneys
functions.
The main processes, which one implement in kidneys
– filtration, reabsorption, secretion.
The main parameters of kidney function – clearance,
efficiency of renal blood circulation, tests on
concentration and delution, residual nitrogen of
blood, data of research of urine.
5. The advices for students.
1. The main function of the kidney is:
a) to filter the plasma
b) selectively reabsorb solutes sodium and water
c) excrete metablolic waste products and toxins
d) secrete as endocrine organ such hormones as renin, erythropoietin,
prostoglandins.
2. Define the renal processes of filtration, reabsorption, and secretion.
Glomerular filtration is the first step in urine formation in which permeable
substances from the blood are filtered at the endothelial-capsular membrane and
the filtrate enters the proximal convoluted tubule.
Net filtration pressure (NFP) is equal to glomerular blood hydrostatic pressure
(GBHP) minus capsular hydrostatic pressure (CHP) plus blood oncotic pressure
(BOP).
NFP = GBNP – (CHP + BOP)
This NFP net filtration pressure can be reduced by renal vasoconstriction,
hypotension, hypovolemia, or low cardiac output. Sympathetic nerve activity
stimulates renal arteriolar vasoconstriction.
Tubular secretion excretes chemicals not needed by the body including
hydrogen and some other acids, urea, creatinine, and some drugs. Secretion adds
material to the filtrate from the blood.
In electrolyte movement between body fluids and cells, electrolyte neutrality
must be maintained in both extracellular and intracellular compartments. It is
necessary that the number of cations equals the number of anions present. This
principle is particularly important in renal function.
3. How is renal function regulated?
There is a variety of physical, hormonal and neural mechanisms by which the
function of the kidneys is controlled. Alteration of sodium balance influences
blood pressure and hence renal perfusion pressure. Sympathetic innervation by the
renal nerves influences renin release. Prolonged development of glomeruli vessels’
spasm leads to the disturbance of sodium and water metabolism and secondary
aldosteronism develops.
4. What quantitative and qualitative disorders of renal insufficiency do you
know?
There are such quantitative disorders as polyuria, oliguria, anuria, nicturia,
pollakiuria while the qualitative ones are proteinuria, hematuria, glucosuria,
lipiduria.
5. What is the manifestation and mechanisms by which altered filtration,
reabsorbtion and secretion of kidneys are observed?
The disorder of filtration is observed in oliguria; the disorder of reabsorption is
seen in edema, and the disorder of secretion results in anemia and hypertension.
6. Acute Renal Failure.
Acute renal insufficiency is characterized by acute disturbance of the
stability of the internal medium of the organism due to considerable and quick
decrease of the rate of the tubular filtration (in the norm 120ml/min, in oligo- and
anuria - 1-10ml/min).
Etiology.
Acute renal insufficiency (ARI) is connected with 3 groups of factors,
prerenal, renal and postrenal. Prerenal factors of ARI are:
1. Blood loss burns, incontrollable vomiting, profuse diarrhea, the use of
diuretics resulting in sharp decrease of the volume of the intravascular and
extracellular fluids.
2. Vascular forms of shock (septic, anaphylactic), accompanied by reduction
of the arterial pressure.
3. Acute (myocardial infarction, embolism of the pulmonary artery)
and chronic cardiac insufficiency.
Renal factors are:
1. Obstruction of the ureter (calculi, tumors).
2. Retention of the urine at the level of the bladder outlet (adenoma of the
prostate).
The main mechanism of ARI development is temporary ischemia of the
kidneys conditioned by hypovolemia, spasm of the afferent arterioles, disseminated
intravascular blood coagulation with microthrombosis or direct damage of the
renal vessels. In consequence there are marked decrease of the filtration pressure
and tubular filtration, switching off of a definite number of the nephrons.
Under the influence of the nephrotoxic factors (toxic, infectious)
along with disturbance of the cortical blood flow, direct damage of the glomerular
and tubular structures becomes important. The rate of the glomerular filtration may
be decreased for the second time due to obstruction of the tubular lumen by
necrotic masses or due to leakage of the filtrate through the wall of the damage
tubules into the interstice. Increased pressure in the capsule of ShumlyanskyBowrnen ог in the interstice results in decrease of effective filtration pressure,
In damage of the cells of the proximal tubule reabsorption of Na+ is
disturbed. Its increased concentration in the distal tubules its taken by macula
dense that results in activation of renin-angiotensin system.
There are four stages in the clinical course of ARI: 1. initial; 2. oligo-,
anuria; 3. polyuria; 4. recovery;
5.1. Content of the theme. The main function of the kidney.Define the
renal processes of filtration, reabsorption, and secretion.How is renal function
regulated? What quantitative and qualitative disorders of renal insufficiency do
you know? What is the manifestation and mechanisms by which altered filtration,
reabsorbtion and secretion of kidneys are observed? Describe the classification of
renal diseases causing Acute Renal Failure.
5.2. Control questions of the theme:
1.The main function of the kidney.
2.Define the renal processes of filtration, reabsorption, and secretion.
3.How is renal function regulated?
4.What quantitative and qualitative disorders of renal insufficiency do you know?
5.What is the manifestation and mechanisms by which altered filtration,
reabsorbtion and secretion of kidneys are observed?
6. Acute Renal Failure.
5.3. Practice Examination.
I. Circle the correct answer or answers for each question.
1. Renal function tests include: A. The urinalysis. B. BUN and serum
creatinine. C. SGOT/SGPT.
D. Both A and B are correct. E. A, B and C are
correct.
2. Which substance is an abnormal constituent of urine? A. Urea. B.
Glucose. C. Sodium chloride. D. Creatinine.
3. The presence of albumin in the urine would indicate probable damage to:
A. Glomeruli. B. Renal columns. C. Collecting tubules. D. Pyramids. E. None of
the above is correct.
4. Which statement is not true concerning urinary tract infections? A. Once
cystitis develops, pyelonephritis will certainly occur. B. They are usually due to
coliforms, especially E.coli. C. Organisms probably entered the bladder by way of
the urethra. D. The patient may be asymptomatic.
5. Renal calculi may be composed of: A. Calcium oxalate. B. Uric acid.
C.Cholesterol. D. All of the above are correct. E. Both A and B are correct.
6. Which is characteristic of ureteral stones? A. Severe pain in back.
B.Severe pain in abdomen. C. Nausea and vomiting. D. All of the above are
correct. E. Both A and C are correct.
7. A common cause of both pyelonephritis and cystitis is: A. Urinary calculi.
B. Invading microorganisms, such as E.coli. C. Allergy reactions. D. Heavy
metals.
8. Uremia exhibits: A. Polycythemia. B. Retention of metabolic acids. C. Low
plasma calcium levels. D. Increased erythropoiesis. E. Both A and B are correct.
9. Which renal condition usually has a history of recent infection
withhemolytic streptococci?
A. Pyelonephritis. B. Chronic renal failure. C. Nephrosis. D.Glomerulonephritis.
E. Calculi.
10. Which is not true concering glomerulonephritis? A. Significant damage
to kidneys occurs during the body’s response to an infection. B. Fever and flank
pain occur. C. It is type III hypersensivity. D. It is characterized by hematuria,
proteinuria, and the presence of casts. E. Approximately 90 % of individuals
develop chronic disease.
11. Nephrotic syndrome is associated with ________ to plasma ______.
A.Increased glomerular permeability / urea. B. Decreased glomerular permeability
/ proteins. C. Decreased glomerular permeability / tubular filtrate. D. Increased
glomerular permeability / proteins.
12. Causes of acute renal failure include: A. Cholecystitis. B. Stones and
strictures in kidneys or ureteres. C. Heart failure leading to poor renal perfusion. D.
Both B and C are correct. E. A, B, and C are correct.
13. Which is not true of chronic renal failure? A. Hyperkalemia. B. Anuria.
C. Anemia. D. Pruritus.
E. Acidosis
14. Chronic renal failure: A. May result from hypertension. B. Is usually the
result of chronic inflammation of the kidney. C. May be treated with dialysis or
transplants. D. All of the above are correct.
E. Both A and C are correct
15. Nephrotoxins such as the antibiotics may be responsible for: A. Acute
tubular necrosis. B. Acute glomerulonephritis. C. Pyelonephritis. D. Cystitis.
16. Uremia, as seen in chronic renal failure, would include: A. Metabolic
acidosis. B. Elevated BUN and creatinine. C. Cardiovascular disturbances. D. All
of the above are correct.
17. An early symptom of chronic renal failure is: A. Pruritus. B. Oliguria.
C.Polyuria. D. Decreased BUN.
18. In chronic renal failure, tubulointerstitial disease leads to: A. Sodium
retention. B. Sodium wasting. C. No significant changes in sodium levels.
D.Increased phosphate excretion.
19. Which of the following are predisposing factors for acute urinary tract
infections? A. Congenital deformities of urinary tract. B. The sex of the patient.
C.Decreased urine flow D. Increased urine flow.
E. Increased fluid intake.
20. Which of the following are true of pyelonephritis? A. Is an inflammation
and infection of the urinary bladder. B. Is characterized by fever, chills, and flank
pain. C. Is characterized by pyuria, bacteriuria, and hematuria. D. Is more common
in young women than in young men.
21. Which of the signs below describe a patient in acute renal failure?
A.Elevated serum creatinine. B. Leukocytosis. C. Low BUN. D. Fever. E. Oliguria.
22. An individual has an elevated blood level of urea and creatinine because
of complete calculi blockage of one ureter. This is referred to as: A. Prerenal
disease. B. Intrarenal disease. C. Postrenal disease. D. Preeclampsia.
E.Hypercalcemia.
II. Match the etiology with the condition. 23. Epithelial proliferation in capsular
space. 24. Hypovolemia.
25. Uremia. A. prerenal failure. B. Postrenal failure. C. Chronic
glomerulonephritis. D. Rapidly progressive glomerulonephritis. E. Pruritus.
Literature:
1.Gozhenko A.I., Makulkin R.F., Gurcalova I.P. at al. General and clinical
pathophysiology/ Workbook for medical students and practitioners.-Odessa, 2001.P.223-226.
2.Gozhenko A.I., Gurcalova I.P. General and clinical pathophysiology/ Study
guide for medical students and practitioners.-Odessa, 2003.- P.290-299.
3.Robbins Pathologic basis of disease.-6th ed./Ramzi S.Cotnar, Vinay Kumar,
Tucker Collins.-Philadelphia, London, Toronto, Montreal, Sydney, Tokyo.-1999.