Urinary-SystemUrinary-System泌尿系统泌尿系统全英文全英文ContentComposition Anatomy Physiology Common diseaseExamination CompositionKidney Ureter Urinary bladderUrethra Part 1 kidneyBean-shape: a concave area on the edge toward the centre called hilum, where renal artery enters the kidney and renal vein leaves it. The ureters also leave the kidneys at the hilum, leading to the bladder.The human kidneys represent about 0.5% of the total weight of the body, but receive 2025% of the total arterial blood pumped by the heart. NephronsThe functional unit of the kidney Responsible for the actual purification and filtration of the blood About one million nephrons are in the cortex of each kidney Consists of a renal corpuscle and a renal tubule The renal tubule consists of the convoluted tubule and the loop of Henle 近端小管近端小管近端小管近端小管远端小管远端小管远端小管远端小管Urine formation proceeds through 3 major processes in the kidney:1.Glomerular filtration-by the glomeruli.2.2. Tubular reabsorption and secretion in the renal tubules.3. Tubular secretionnephronrenal corpusclerenal tubuleglomerular capsule(Bowmans capsule)glomerulusafferentarterioleefferentarteriole肾单位肾单位肾小体肾小体肾小球肾小球Urine formation proceeds through 3 major processes in the kidney:1. Glomerular filtration-by the glomeruli.2. Tubular reabsorption and secretion in the renal tubules.3. Tubular secretionWorking mechanism of the kidneys: Blood is brought to the kidney via the renal artery. The kidneys filter the blood and then reabsorb useful materials such as glucose. After it has been purified the blood returns to the circulation through the renal vein.New words about kidneyGeneral EnglishRootEg.kidneyRen/oRenographySuprarenalLienorenalNephr/oNephritisHydronephrosisRenal pelvisPyel/oPyelographyPyelonephritisPelvi/opelvilithotomy pelvioplastyGlomerularGlomerul/oGlomerulonephritisPart 2 Ureters Two muscular tubes which convey the urine from the renal pelvis to the urinary bladder.Each measures 20-30cm in length, 0.5-0.7cm in diameter.According to the course, each ureter can be divided into 3 parts: Abdominal part Pelvic part Intramural partThree constrictions:n1st: at pelviureteric junctionn2nd : where ureter crosses the pelvic inlet and iliac vesselsn3rd : at intramural partNew words about uretersGeneral General EnglishEnglishRootRootEg.Eg.UretersUreter/oUreteroceleUreterographyUreterostenosisUreterorrhaphyPart 3 Urinary bladder The urinary bladder is a hollow muscular organ situated in the pelvic cavity posterior to the pubic symphysis. In the floor of the urinary bladder is a small, smooth triangular area, the trigone. The ureters enter the urinary bladder near two posterior points in the triangle; the urethra drains the urinary bladder from the anterior point of the triangle.New words aboout urinary bladderGeneral EnglishGeneral EnglishRootRootEg.Eg.Urinary bladderVesic/oIntravesicalvesicoureteralCyst/oCystitisCystographyCystoptosiscystostomy Part 4 Urethra Female urethra isrelatively shorter(about 3-5cm long),wider and straighter.nInternal orifice of urethra nExternal orifice of urethra：(opens into vaginal vestibule)New words about urethra and urineGeneral EnglishGeneral EnglishRootRootEg.Eg.UrethraUrethr/oUrethritisUrethrograpyMeat/oMeatorrhaphyMeatotomyUrineUrin/oUrinogenitialUrinationUr/oHematuriaUrobilin PolyuriaAnuriaTHE URINARY SYSTEMIncluding the kidneys, ureters, urethra and urinary bladder.The kidneys are the primary excretory in the human body. They function by removing toxins from the body while returning necessary compounds back to the body.The kidneys filter approximately 200 liters of fluid from the body everyday.The Primary Functions of the Urinary System include:1. Filtering waste products of metabolism from the blood and removing the wastes from the body via the urine；2. Responsible for homeostasis:nRegulate the level of electrolytes such as sodium, potassium, chloride, bicarbonate.nMaintain the correct pH range within the body3. Endocrine function：Producing the enzyme Renin which regulates blood pressure and proper kidney functioning；Producing the hormone Erythropoietin （EPO）which regulates and stimulates erythrocytes production;Metabolizing vitamin D to its active form. Mechanism Urinary Systemfilter and remove waste products from the bloodproduction and excretion of urinemain functionresult in Urinary system diseases The most common disease list Acute renal failure (ARF) Chronic renal failure (CRF) Urinary tract infection Urinary calculus Primary glomerular disease Acute glomerulonephritis (AGN) Chronic glomerulonephritis(CGN) Nephrotic syndrome(NS) A kidney infection Acute pyelonephritis Chronic pyelonephritis Cystitis Perinephric abscess Renal damage in metabolic disease Diabetic nephropathy Hyperuricemia nephrosis auxiliary examinationHow to use the auxiliaryexamination(辅助检查) in diagnosisof urinary system diseases ?nIconographynUrinalysisnRenal biopsynKidney function test IconographynX-ray examination： （1）Plain abdominal radiograph （radio- 放射，-graph 描绘、记录， radiograph X光照片 ） （2）Urography： Excretory urography Retrograde urography （retro- 向后、倒退， Retrograde 逆行性） Selective renal arteriography nCT detection Plain scan CT Enhanced CT nMagnetic Resonance Imaging nUltrasonography （ultrasono- 超声）Comparation and Preference 1. Urography examination use for hydronephrosis , ureterectasis and congenital anomaly detection and diagnosis, as well as preoperative assessment of the value of the contralateral kidney function . 2.CT examination can be used in the founding of vast majority of tumors, stones, cysts and other diseases and congenital anomalies. 3. MRI is often used as secondary screening method of atypical lesions for further diagnosis and differential diagnosis. Urinalysis1.A urinalysis (UA) , is an array of tests performed on urine, and one of the most common methods of medical diagnosis.2.The target parameters that can be measured or quantified in urinalysis include many substances and cells, as well as other properties, such as specific gravity.3.It is the main basis for diagnosis of kidney injury. Urinalysis Methods1.Urine test strip nLeukocytes with presence in urine known as leukocyturianNitrite with presence in urine known as nitriturianProtein with presence in urine known as proteinuria, albuminuria, or microalbuminurianBlood with presence in urine known as hematurianspecific gravity比重The numbers and types of cells and/or material such as urinary casts can yield a great detail of information and may suggest a specific diagnosis.Hematuria associatedwithkidneystones,infections,tumorsandotherconditionsPyuriaassociatedwithurinaryinfectionsEosinophiluriaassociatedwithallergicinterstitialnephritis,atheroembolicdiseaseRed blood cell castsassociatedwithglomerulonephritis,vasculitis,ormalignanthypertensionWhite blood cell castsassociatedwithacuteinterstitialnephritis,exudativeglomerulonephritis,orseverepyelonephritis(Heme) granular castsassociatedwithacutetubularnecrosisCrystalluriaassociatedwithacuteuratenephropathy(oracuteuricacidnephropathy,AUAN)Calcium oxalatinassociatedwithethyleneglycol2.Microscopic examination3.Other methods of urinalysisnUrine culture a microbiological culture of urine samples, detecting bacteriuria, is indicated when a urinary tract infection is suspected.nIctotest this test is used to detect the destruction of old red blood cells in the urine.nHemoglobin test this tests for hemolysis in the blood vessels, a rupture in the capillaries of the glomerulus, or hemorrhage in the urinary system, which cause hemoglobin to appear in the urine. Renal biopsy Renal biopsy , often used in the diagnosis of kidney diseases, is regarded as the gold standard of the glomerular disease. It can not only guide our treatment options, but also timely reflect the prognosis and determine the therapeutic effect. Sometimes we need to repeat it. kidney function testClearance rate: Glomerular filtration rate GFR Endogenous creatinine clearance rate ，Ccr Renal blood flow RBFConcentration-dilution test（浓缩稀释试验）（ARF）DifinitionClassificationPathogenesisDiagnosisDifferential TreatmentPrognosisDefinitionnAcute renal failure （ARF）is a syndrome characterized by a relatively rapid decline in renal function that leads to the accumulation of water , crystalloid solutes , and nitrogenous metabolites in the body. Classificationn Prerenal Acute Renal Failuren Postrenal Acute Renal Failuren Intrarenal Acute Renal Failure EtiologyDiabeticnephropathyHypertensivenephrosclerosisPrimaryorsecondaryglomerulonephritisTubulointerstitialdisease（tubulo- 管， tubulointerstitial 小管间质性 ）Renalvasculardisease（vas- 血管、输精管）Hereditarykidneydiseases Main Mechanismn renal hemodynamic changes n renal ischemia （reperfusion cell damage) n acute tubular damagePathogenesisDecreased Renal blood flowRenal ischemiaIschemia-reperfusion injury GFRAcute renal tubular damageHypovolemiaThe resistance of afferent arteriole increasedRenal poisoningARFPathology of acute renal failurenIn general： nephromegaly , kidney is pale, Renal cortex is pale and Renal medulla is dark red.n（-megaly 异常扩大，eg. Splenomegaly cardiomegaly）nMicroscope: renal tubular epithelial cells are degenerative, necrotic and deciduous .nToxicant cause: Pathological changes is uniform in the proximal tubule, glomerular basement membrane(GBM) is relatively complete.nIschemia cause: Pathological changes is not uniform in medullary thick ascending limb and distal convoluted tubule, glomerular basement membrane(GBM) is fractured.NephroNephromegaly normal kidneymegaly normal kidneyThe epithelial cells of renal proximal convoluted tubule are hydropic（eg：The most striking change in the tubules is hydropic degeneration of the epithelium. Pathological sectionsManifestations of acute renal failurenOliguric acute renal failure oliguric stage diuretic stage recovery stagenNonoliguric acute renal failure Manifestations of Oliguric acute renal failure 1.The initial phase The primary disease performance: Hypotension，Manifestations caused bybleeding 、infection、poison and so on.(1) General symptoms of each systemThe digestive system dyspnea，thoracalgia The respiratory system hypertension，myocardiosis The circulatory system nausea，vomiting The nervous system hemorrhage，anemia The blood system uremic encephalopathy coma2.Maintenance phase (oliguric stage)(2) Water, electrolyte and acid-base balance disordersMetabolic acidosis：weak 、cephalalgia、coma 、arrhythmiahyperpotassaemia(K+5.5mmol/L )： early stage ：no characteristic manifestations. later stage ：weak、tendon reflex disappearing、drowsiness、arrhythmia. Hyperpotassaemia is one of the most common causes of death！ hyponatremiahapntrem (Na+135mmol/L) hypochloraemiahapkl:ri:mj (Cl-95mmol/L) hypocalcemia hapklsi:m (Ca2+1.61mmol/L)(2) Water, electrolyte and acid-base balance disorders3. recovery phase (diuretic stage) Hydrouria :more than 3000ml-5000ml /d.nEarly stage: the markely elevated Creatinine (Cr) and blood urine nitrogen(BUN) levelsnLater stage : hyponatremia , dehydration nAll kinds of complications can still exist nA few patients have severe and permanent renal function damages.Manifestations of Nonoliguric acute renal failure Characteristics:nunobvious oligurianlow specific gravity of urinenlow urinary sodium levels nazotemianmost patient have not hyperpotassaemiaDiagnostic criteriaThe serum creatinine of absolute value of average daily increase of 44.2 mol/L, or 88.4 mol/L; or in the 24 72 hours blood creatinine values increased from 25% to 100%.Differential diagnosis1. Firstly, we should exclude the ARF based on the CKD( chronic kindny diseases),which can be evidenced from the following signs:double kidney shrinks,anemia, uremia face and renal neuropathy . 2. Secondly we should exclude prerenal and postrenal causes.3. After the determination of renal ARF, there should be differentiated whether it is causaed by glomerular, renal vascular or tubulointerstitial lesions.(1)ATN vs. Pre-renal oligurianFluid infusion test Prior to the onset ,there are medical history such as capacity lack and body fluid loss etc.If the physical examination found skin and mucous membranes dry,and hypotension, we should consider firstly the prerenal oliguria.At this time you can try to infuse and inject loop diuretics for observing the load of circulatory system after infusion . If the blood pressure returned to normal and urine volume increased after the supplement of blood volume , it supports the diagnosis of prerenal oliguric. The hypotension lasts for at long time, especially for the elder with heart dysfunction and without increased urine output after fluid infusion ,it should be suspected that prerenal azotemia have transformed into ATN. (2)ATN vs. urinary tract obstruction Post-renal obstruction of the urinary tract:1.Cause：stone/tumor /prostatauxe2.Symptom：anuria or intermittent anuresis suddenly; Renal colic, rib abdomen or abdominal pain; Renal percussive pain ;3.Auxiliary examination： Ultrasonography and X-ray examination can help diagnosisTreatment and prognosis of acute renal failureThe principle of treatmentnTreatment of primary disease nTreatment based on symptoms 1. Strictly control the liquid intake 2. Treatment of hyperkalemia 高钾血症高钾血症 3. Correction of metabolic acidosis 代谢性酸中毒代谢性酸中毒 4. Therapy of azotemia 氮质血症氮质血症 5. Dialysis therapy 透析疗法透析疗法 Treatment Correct the reversible etiology, prevent additional damage:nActive treatment of the primary disease, eliminate the factors that lead to or exacerbate(加重) ARF ；n Quickly and accurately supplement the blood volume, maintain effective circulating blood volume enough；n Prevent and correct low perfusion, avoid the use of nephrotoxic drugs。Treatment Maintain fluid balance Fluid volume is equal to dominant fluid loss add non dominant fluid loss subtract the endogenous content补液量显性失液量非显性失液量内生水量补液量显性失液量非显性失液量内生水量 Estimating: the liquid feeding amount is equal to amount of urine add 500ml 估算：进液量尿量估算：进液量尿量ml Treatment Diet and nutritionWe should provide sufficient heat, thereby reducing to break down.protein.n carbohydrate and fat n Protein restriction is 0.8g / (kg d)n As much as possible to reduce the intake of sodium(钠) , potassium(钾) and chloride(氯).Treatment Hyperkalemia （Hyperkalemia 6.5mmol / L, ECG abnormality）n l0% calcium gluconate 10 20ml after dilution (IV 5 minutes)n 5% sodium bicarbonate 100ml iv dropn 50% glucose 50ml add 10U insulin iv drop slowly n Oral: ion exchange resin交换树脂 n Dialysis Treatment Metabolic acidosis (HCO3 15mmol / L) Itcanbetreatedwith5%sodiumbicarbonate100250mlintravenousdrip,Severeacidosisshouldbeimmediatelytreatedbydialysis. Infection nTheearlyuseofantibioticnAccordingtothedrugsensitivetest,lownephrotoxicdrugsshouldbechosen.nAdjustthedosageaccordingtoendogenouscreatinineclearancerateTreatment Heart failure The diuretic response is poor in patients with ARF nDigitalis effect is poor, prone to digitalis poisoningnEnlarge blood vessel drugs can reduce cardiac loadnThe most effective therapy is dialysis to the patients with volume overload heart failure Treatment Dialysis therapy Dialysis method: nIntermittent Intermittent hemohemodialysisdialysis（）（）nPeritoneal dialysisPeritoneal dialysis（）（）nContinuous renal replacement Continuous renal replacement therapytherapy（）（） Emergency dialysis indications nDrug can not control the hyperkalemia (6.5mmol/L);nWater retention、oliguria 、 anuria 、 highly swollen、pneumonedema 、encephaledema and hydropericardium,which can not be controled by drugs.nUncontrolled hypertension nMetabolic acidosis drugs can not be corrected (PH7.2)nUremic pericarditisnGastrointestinal tract bleeding, nThe Central Nervous system symptoms : trance, drowsiness , coma, convulsions , psychiatric symptoms.Prognosis The main causes of death are theprimary diseases, complications,especially multiple organ failure,infections. The development ofchronic renal failure is rare.结束结束