M.D., PhD. Marta R. Gerasymchuk, Pathophysiology Department Ivano-Frankivsk National Medical University

1. Pathophisiology ofPathophisiology of
kidneys.kidneys.
Renal insufficiency.Renal insufficiency.
M.D., PhDM.D., PhD, Associate Professor, Associate Professor
Marta R. Gerasymchuk,Marta R. Gerasymchuk,
Pathophysiology DepartmentPathophysiology Department
Ivano-Frankivsk NationalIvano-Frankivsk National
Medical UniversityMedical University

2. 1.1. Disorders of secretory and incretory functions of kidneys.Disorders of secretory and incretory functions of kidneys.
2.2. Insufficiency of kidneys: definition, classification,Insufficiency of kidneys: definition, classification,
reasons.reasons.
3.3. Violation of glomerulus filtration: reasons andViolation of glomerulus filtration: reasons and
mechanisms. Changes of obligate diuresis: kinds, reasonsmechanisms. Changes of obligate diuresis: kinds, reasons
and consequences of oliguria and anuria. Polyuria: kinds,and consequences of oliguria and anuria. Polyuria: kinds,
reasons, consequences. Nycturia: kinds, mechanisms ofreasons, consequences. Nycturia: kinds, mechanisms of
development.development.
4.4. Violation of processes of reabsorbtion in tubulus.Violation of processes of reabsorbtion in tubulus.
Violation of tubular secretion.Violation of tubular secretion.
5.5. Pathological components of urine. Functional tests ofPathological components of urine. Functional tests of
kidneys, their using in a clinic.kidneys, their using in a clinic.
6.6. Acute and chronic glomerulonephritis. Etiology,Acute and chronic glomerulonephritis. Etiology,
pathogenesis, clinical symptoms and mechanism ofpathogenesis, clinical symptoms and mechanism of
development of them. Experimental models.development of them. Experimental models.
7.7. Acute and chronic pyelonephritis. Etiology, pathogenesis,Acute and chronic pyelonephritis. Etiology, pathogenesis,
clinical symptoms.clinical symptoms.
8.8. Urolithiasis. Theories of stone formation. Clinical picture.Urolithiasis. Theories of stone formation. Clinical picture.
ContentContent

3. Actuality of the themeActuality of the theme
 Kidneys play important role in regulation of constancy of internalKidneys play important role in regulation of constancy of internal
environment. Most functions of kidneys related to the processes ofenvironment. Most functions of kidneys related to the processes of
uropoiesisuropoiesis and urination. Due to these processes kidneys take part inand urination. Due to these processes kidneys take part in
support of water-electrolyte and acid-base balances. The excretionsupport of water-electrolyte and acid-base balances. The excretion
function of kidneys provides the release of organism from the finishedfunction of kidneys provides the release of organism from the finished
goods of metabolic and different toxic substances.goods of metabolic and different toxic substances. Violation ofViolation of
uropoiesis and urination is accompanied by violation of vital functionsuropoiesis and urination is accompanied by violation of vital functions
of organism.of organism.
 The renal failure depend to severe pathological states. The disorder ofThe renal failure depend to severe pathological states. The disorder of
constance of internal environment of organism, which one thus arise,constance of internal environment of organism, which one thus arise,
often demand emergency treatment. To the most often causes, whichoften demand emergency treatment. To the most often causes, which
one cause disturbance of functions of kidney, the disorder of theirone cause disturbance of functions of kidney, the disorder of their
blood supply, infections deseases, intoxication, autoallergy damages,blood supply, infections deseases, intoxication, autoallergy damages,
violation of outflowviolation of outflow of urine concern. Knowledge of etiology andof urine concern. Knowledge of etiology and
pathogenesis of kidney diseases, mechanisms of disturbance, whichpathogenesis of kidney diseases, mechanisms of disturbance, which
one arise in renal failure, are necassary for selection pathogeneticone arise in renal failure, are necassary for selection pathogenetic
based methods of preventive maintenance and treatment.based methods of preventive maintenance and treatment.

4. Functions of the kidneyFunctions of the kidney
EliminationElimination
of waste/surplusof waste/surplus
Carbohydrate-derivedCarbohydrate-derived
NitrogenousNitrogenous
OtherOther
Water, acidWater, acid
Urea creatinine, uric acid,Urea creatinine, uric acid,
guanidine, amines, etcguanidine, amines, etc
Sulphate, phosphate,Sulphate, phosphate,
exogenous toxins, etc.exogenous toxins, etc.
RegulationRegulation
of fluid andof fluid and
electrolyteelectrolyte
balancebalance
Total body waterTotal body water
Plasma osmotic pressure, pHPlasma osmotic pressure, pH
Na, K, Ca, Mg, etc.Na, K, Ca, Mg, etc.
Chloride, bicarbonate,Chloride, bicarbonate,
phosphate, etc.phosphate, etc.
EndocrineEndocrine
homeostasishomeostasis
Blood pressureBlood pressure
Calcium and bone metabolismCalcium and bone metabolism
RBC productionRBC production

5. 1. Water balance1. Water balance
Osmoreceptor (hypothalamus)Osmoreceptor (hypothalamus)
ADH, Vasopressin (Pituitary)ADH, Vasopressin (Pituitary)
Collecting ductCollecting duct
Absorption of HAbsorption of H22OO
FunctionFunction of Kidneyof Kidney
2. Acid-base balance2. Acid-base balance
Carbonic anhydrase (Distal tubules)Carbonic anhydrase (Distal tubules)
Carbonic acid-bicarbonate buffer systemCarbonic acid-bicarbonate buffer system
H+ excretionH+ excretion
Na+ reabsorptionNa+ reabsorption
HH22O excretionO excretion

6. 3. Excretion of waste product3. Excretion of waste product
- Acid - base - H- Acid - base - H22OO
- creatinine- creatinine
- Metabolites- Metabolites
4. Others4. Others - erythropoeitin- erythropoeitin
Conclusion :
renal functions
Filtration
Reabsorption
Secretion

8.  KidneyKidney is majoris major organorgan, which determine, which determine
outcell liquid of an organismoutcell liquid of an organism
persistance and regulates structurepersistance and regulates structure
surroundy cells environmentalsurroundy cells environmental
 The kidney prevent internal changesThe kidney prevent internal changes
and provide maintenance such mainand provide maintenance such main
homeostasis parametershomeostasis parameters as:as:
 iisovolemiasovolemia – blood volume constancy– blood volume constancy
 isotoniaisotonia – osmotic pressure– osmotic pressure
constancyconstancy
 isoioniaisoionia – ionic structure constancy– ionic structure constancy
 isohydriaisohydria – concentration hydrogen– concentration hydrogen
ions constancyions constancy

9. Homeostasis maintenance
includes three processesthree processes:
plasma filtering by glomerulus
selective canalicules reabsorbtionreabsorbtion
ions of hydrogen secretionsecretion
ammonium and other substances secretion
Structural and functional unit of a kidneyunit of a kidney,
which provides these functions is nephronnephron

10. NEPHRONNEPHRON

12. Disorders of theDisorders of the excretoryexcretory
functions of kidneys lead to:functions of kidneys lead to:
 1) violation of1) violation of water homeostasiswater homeostasis. It is changes of volume. It is changes of volume
of extracellular liquid (of extracellular liquid (hyperhyper-- and hypohydriaand hypohydria););
 2) violation of2) violation of osmotic homeostasisosmotic homeostasis -- hyperhyper-- andand
hypoosmiahypoosmia;;
 3) violation of balance of3) violation of balance of electrolyteselectrolytes in a extracellularin a extracellular
liquid (liquid (dysioniadysionia););
 4) violation of4) violation of acid-base balanceacid-base balance (more frequent in all is(more frequent in all is
nongaseous acidosis);nongaseous acidosis);
 5) violation of chemical composition of plasma of blood5) violation of chemical composition of plasma of blood
which shows up, from one side, piling up of the finishedwhich shows up, from one side, piling up of the finished
goods of metabolism (azotemia [uremia]), from other, - bygoods of metabolism (azotemia [uremia]), from other, - by
the loss of necessary to the organism of organicthe loss of necessary to the organism of organic
compounds (compounds (hypoproteinemia, hypoaminoemia,hypoproteinemia, hypoaminoemia,
hypoglycemiahypoglycemia).).

13. Disorders of incretory functions ofDisorders of incretory functions of
kidneys show up by violations:kidneys show up by violations:
1) secretions of renin by the JGA of kidneys,1) secretions of renin by the JGA of kidneys,
and also kidney depressor factors;and also kidney depressor factors;
2)2) production of erythropoietins andproduction of erythropoietins and
inhibitors of erythropoiesisinhibitors of erythropoiesis;;
3) transformation of vitamin D to hormonal3) transformation of vitamin D to hormonal
of active form.of active form.
Disorders of incretory function of kidneysDisorders of incretory function of kidneys
can stipulate development:can stipulate development:
1) arterial hypertension;1) arterial hypertension;
2) anemias;2) anemias;
3) kidney osteodysrtrophy - violation of3) kidney osteodysrtrophy - violation of
phosphoric-calcium metabolism.phosphoric-calcium metabolism.

14.  Intensity of kidney blood stream (Intensity of kidney blood stream (QQ) in) in
a norm is ever-higher: abouta norm is ever-higher: about 11001100
ml/minml/min, or to a 25% volume of blood, or to a 25% volume of blood
which is pumped over for a minute bywhich is pumped over for a minute by
a heart in a state of rest It is calculateda heart in a state of rest It is calculated
after a formula:after a formula:
Pa – Pv 8Pa – Pv 8ηηll
 Q = ; R =Q = ; R =
RR ππr4r4
 wherewhere QQ is volume speed ofis volume speed of
kidney blood stream;kidney blood stream;
 PaPa is pressure at the beginning;is pressure at the beginning;
 PvPv - at the end of the system of- at the end of the system of
perfusion of kidney vessels;perfusion of kidney vessels;
 RR - is resistance of kidney- is resistance of kidney
vessels;vessels;
 ηη -- is viscosity of blood;is viscosity of blood;
 ll - is length of vessels;- is length of vessels;
 rr - is a radius of vessels.- is a radius of vessels.

15. After that formula diminishing of intensity ofAfter that formula diminishing of intensity of
kidney blood stream it can be conditioned by:kidney blood stream it can be conditioned by:
► 1)1) diminishing of arterial pressure (Pa)diminishing of arterial pressure (Pa) below 80 mmHgbelow 80 mmHg
(the mechanism of myogenic autoregulation don’ work).(the mechanism of myogenic autoregulation don’ work).
It is observed at all types of shock and collapse;It is observed at all types of shock and collapse;
► 2)2) multiplying venous pressure (Pv).multiplying venous pressure (Pv). Reason of it can be: a)Reason of it can be: a)
general violations (right ventricle insufficiency of heartgeneral violations (right ventricle insufficiency of heart
which results in multiplying central and peripheral venouswhich results in multiplying central and peripheral venous
pressure),pressure),
b)b) local disorderslocal disorders (venous hyperemia, for ex. as result of(venous hyperemia, for ex. as result of
inflammation of kidney tissue); r4inflammation of kidney tissue); r4
► 3)3) diminishing of radiusdiminishing of radius (r)(r) of vesselsof vessels (an ischemia of(an ischemia of
kidneys is at atherosclerosis and arterial hypertension);kidneys is at atherosclerosis and arterial hypertension);
► 4)4) multiplying viscidity of bloodmultiplying viscidity of blood (η)(η) (at a disseminate blood(at a disseminate blood
clotting).clotting).
► All noted violations lead to diminishing of filtration pressureAll noted violations lead to diminishing of filtration pressure
in kidney glomerulus, that shows up diminishing of speedin kidney glomerulus, that shows up diminishing of speed
of filtration and, consequently, by the signs of insufficiencyof filtration and, consequently, by the signs of insufficiency
of kidneys.of kidneys.

16. GFRGFR measurement is possible if one has a substance (call it x) that is
freely filterable at the glomerulus and then is not reabsorbed, secreted,
or changed in any way before it appears in the urine. To calculate the
GFR from this substance, one would measure its concentration in a
plasma sample (PxPx), its concentration in a urine sample (UxUx), and the
urine volume over a certain period of time (VV). Given these values, the
equation for GFR, in milliliters per minute, can be solved as shown in:
Ux (mg/mL) V (mL/min)
GFR (mL/min) =
Px (mg/mL)
The classic substance that fits the criteria described above for substance
xx is the polysaccharide inulininulin. However, inulin is not normally present in
the body, which means using inulin to measure GFR involves infusing it
into an individual for an extended period. This offers a highly accurate
but impractical method for measuring GFR.
Instead, what is usually measured in plasma and urine is the
concentration of creatinine, which is a naturally produced protein.

17. Filtration disorderFiltration disorder
GlomerulesGlomerules filtfiltrationration processprocess is possible tois possible to
consider asconsider as water and moleculeswater and molecules pushingpushing throughthrough
sieve under infuence of arterialsieve under infuence of arterial pressure in apressure in a
remote capillaryremote capillary
This passive process dependsThis passive process depends on hydrostatic
exacter filtration pressure, which displace a liquid
part from capillary blood into a canaliculus lumen
of and does not require energy
FiltrationalFiltrational pressurepressure, which predetermines
glomerules filtrate derivation, is equal to 15-15-25 mm25 mm
HgHg
In case such filtrational pressure in healthy person
Broumen capsule 120 ml of filtrate per 1 min is
derivated, that is 180 l per one day
The glomerules filtation can be decreased ordecreased or
increasedincreased

18. GGeriatric Considerationeriatric Consideration
• GFR declines with age due to a 30 to 50% loss of functional
nephrons and reduced renal blood flow.
• Such a decline means that when drugs normally cleared by the
kidneys are given to an elderly individual, their dosage should
be adjusted to reflect declining renal function.
• However, because muscle mass, and therefore serum
creatinine, also declines with age, the increase in serum
creatinine level that normally indicates a fall in GFR may not be
apparent.
• Since serum creatinine levels are frequently used to determine
drug dosing, elderly individuals may receive inappropriately
high doses of drugs despite reduced kidney function.
• This problem can have severe toxic consequences. In order to
adjust for age on GFR, the following equation has been
developed by Cockcoft and Gault:
(140 – age) x (body weight in kg)
• Creatinine Clearance =
72 x serum creatinine in mg/dL

19. Reason of filtration decrease:Reason of filtration decrease:
• 1. Hydrostatic pressure decrease in glomerules capillaries: in
general decreasing of arterial pressure decrease (heart
insufficiency, shock, collapse, hypovolemia), narrowing
glomerules afferent arterioles (arterial hypertension, pain):
aorta and kidneys arteries organic defeats (aorta coarctation,
stenosis aorta atherosclerosis due to hypertonic illness),
kidneys arteries thrombosis or embolism
• 2. Plasma oncotic pressure increase – protein blood
substitutes transfusion in large volumes
• 3. Intrakidney pressure increase – canalicules block with
cylinders or urinary tract with stones
• 4. Glomerulus filter disorder – quantity functioning
glomerulus decrease, glomerulus a membrane thickening,
an pores amount and diameter decrease, basal membrane
glycoproteid components autoallergic defeat

20. The most characteristic manifestations ofThe most characteristic manifestations of filtfiltrationration limitation inlimitation in
glomerulesglomerules areare::
 nitrogenemianitrogenemia (accumulation in blood of nitrogen metabolic and blood(accumulation in blood of nitrogen metabolic and blood
residual nitrogen increase)residual nitrogen increase)
 renal nitrogenemic acidosisrenal nitrogenemic acidosis owing to delay in an organismowing to delay in an organism
phosphates, sulfates and organic acidsphosphates, sulfates and organic acids
 Increase of filteringIncrease of filtering performs resulting blood pressure increaseperforms resulting blood pressure increase
excessive consumption water, decomplication edema or oncoticexcessive consumption water, decomplication edema or oncotic
plasma pressure decrease (hepatitis, cirrhosis)plasma pressure decrease (hepatitis, cirrhosis)
Major increasedMajor increased glomerulusglomerulus filter permeabilityfilter permeability manifestationsmanifestations concernconcern::
 proteinuriaproteinuria – evacuation with urine of plasma proteins over– evacuation with urine of plasma proteins over
physiological norm (30-80 mg/day) and in urine protein fractionsphysiological norm (30-80 mg/day) and in urine protein fractions
appearance with molecular weight more than 70 kDappearance with molecular weight more than 70 kD
 hematuriahematuria – erythrocytes kidneys outlet in canalicules lumen of and– erythrocytes kidneys outlet in canalicules lumen of and
their appearance.their appearance.

21. Multiplying ofMultiplying of glomerularglomerular
filtrationfiltration
 1)1) Increase of hydrostatical pressureIncrease of hydrostatical pressure in the capillaries ofin the capillaries of
glomerulus, that is observed at following situations:glomerulus, that is observed at following situations:
a)a) increaseincrease the volume ofthe volume of intravascular liquidintravascular liquid;;
b)b) increaseincrease the volume ofthe volume of speed of cortical blood streamspeed of cortical blood stream inin
connection with diminishing of tone of vas afferens (in theconnection with diminishing of tone of vas afferens (in the
stage incrementi of temperature at a feverstage incrementi of temperature at a fever, in the conditions, in the conditions
ofof multiplying the amount of sodium in a mealmultiplying the amount of sodium in a meal););
c)c) increase of tone of taking arteriolesincrease of tone of taking arterioles under neuro-reflex andunder neuro-reflex and
humoral influencing, which are observed in the early stagehumoral influencing, which are observed in the early stage
of hypertensive illness, after transfusion, at introduction ofof hypertensive illness, after transfusion, at introduction of
small doses of adrenalin.small doses of adrenalin.
 2)2) Decline of oncotic pressure of bloodDecline of oncotic pressure of blood, redistribution of, redistribution of
proteins factions of blood (proteins factions of blood (increase globulinsincrease globulins, which own, which own lowlow
oncotic act – at hepatitis, cirrhosis of liveroncotic act – at hepatitis, cirrhosis of liver).).

22. formation of
hyperosmotic
urine
RenalRenal
ReabsorptionReabsorption
ReabsorptionReabsorption is theis the
second process by whichsecond process by which
the kidney determinesthe kidney determines
the concentration of athe concentration of a
substance filtered fromsubstance filtered from
the plasma.the plasma.
ReabsorptionReabsorption refers torefers to
the active (requiringthe active (requiring
energy and always beingenergy and always being
mediated by a carrier) ormediated by a carrier) or
the passive (no energythe passive (no energy
required) movement of arequired) movement of a
substance filtered at thesubstance filtered at the
glomerulus back into theglomerulus back into the
peritubular capillaries.peritubular capillaries.
ReabsorptionReabsorption may bemay be
totaltotal (e.g., glucose) or(e.g., glucose) or
partialpartial (e.g., sodium,(e.g., sodium,
urea, chloride, andurea, chloride, and
water).water).

23. Reabsorption of GlucoseReabsorption of Glucose
 Glucose is freely filtered at the glomerulus.Glucose is freely filtered at the glomerulus.
 All of the filtered glucose is normallyAll of the filtered glucose is normally reabsorbed by active transportreabsorbed by active transport,,
primarily in the proximal tubuleprimarily in the proximal tubule..
 Because carriers are involved, a transport maximum (Tm) for glucose canBecause carriers are involved, a transport maximum (Tm) for glucose can
be reached. The Tm is the amount of a substance that can be transportedbe reached. The Tm is the amount of a substance that can be transported
per unit of time.per unit of time.
 For glucose, at a certain filtered load (GFR Г— plasma concentration), allFor glucose, at a certain filtered load (GFR Г— plasma concentration), all
carriers become occupied. Any glucose filtered beyond that load is notcarriers become occupied. Any glucose filtered beyond that load is not
reabsorbed, but is instead excreted in the urine. The Tm for glucose isreabsorbed, but is instead excreted in the urine. The Tm for glucose is
approximately 375 mg/min of filtered glucose.approximately 375 mg/min of filtered glucose.
 The concentration of glucose that results in this filtered load, given a GFR ofThe concentration of glucose that results in this filtered load, given a GFR of
125 mL/min, is 3.0 mg/mL of plasma because glucose concentration125 mL/min, is 3.0 mg/mL of plasma because glucose concentration
clinically is frequently expressed as per 100 mL of blood, or, 300 mg/dL.clinically is frequently expressed as per 100 mL of blood, or, 300 mg/dL.
However, glucose begins to appear in the urine even before this plasmaHowever, glucose begins to appear in the urine even before this plasma
level is reached, because each nephron has a slightly different Tm and thelevel is reached, because each nephron has a slightly different Tm and the
carrier transport rate may accelerate at the highest glucose concentrations.carrier transport rate may accelerate at the highest glucose concentrations.
Plasma glucose seldom gets high enough that glucose Tm is reachedPlasma glucose seldom gets high enough that glucose Tm is reached
unless an individual hasunless an individual has diabetes mellitusdiabetes mellitus..
 Note that the kidney does not control blood glucose levels; it simply filtersNote that the kidney does not control blood glucose levels; it simply filters
and reabsorbs all it can. The pancreas, via insulin release, controls bloodand reabsorbs all it can. The pancreas, via insulin release, controls blood
glucose.glucose.

24. Reabsorption disorderReabsorption disorder
 ReabsorptionReabsorption of glucose takes place by it phosphorilation on the membranesof glucose takes place by it phosphorilation on the membranes
of epitheliocytes ofof epitheliocytes of tubulestubules by the enzyme of glucokinase (hexokinase) andby the enzyme of glucokinase (hexokinase) and
glucosoglucoso-6--6-phosphatase, which are produced by epithelial cells. If thephosphatase, which are produced by epithelial cells. If the
concentration of glucose in blood and primary urine (filtrate) does not exceedconcentration of glucose in blood and primary urine (filtrate) does not exceed
180 mg% (10 mmol/l), glucosuria is absent.180 mg% (10 mmol/l), glucosuria is absent.
 Reabsorbtion clearance after glucose = 0Reabsorbtion clearance after glucose = 0
R e a s o n s ofR e a s o n s of glucosuriaglucosuria::
 a)a) alimentary (surplus use of carbohydrates),alimentary (surplus use of carbohydrates),
 b)b) diabetes mellitus (diabetes mellitus (diminishing of products of insulin lead to grows concentrationdiminishing of products of insulin lead to grows concentration
of glucose in blood over 180 mg%, in addition, there is a decline of activity ofof glucose in blood over 180 mg%, in addition, there is a decline of activity of
glucokinase of epithelium cells of kidneyglucokinase of epithelium cells of kidney tubulestubules),),
 c)c) damage of epithelium ofdamage of epithelium of tubulestubules (dystrophic changes, necrosis),(dystrophic changes, necrosis),
 d)d) the inherited deficit of glucokinase (hexokinase) and glucose-6-the inherited deficit of glucokinase (hexokinase) and glucose-6-
phosphatase,phosphatase,
 e)e) poisoning of floridzinpoisoning of floridzin (it is polysaccharide, which contain in glue of fruit trees(it is polysaccharide, which contain in glue of fruit trees
conduces to blocking of processes of phosphorilation glucose in the epithelium ofconduces to blocking of processes of phosphorilation glucose in the epithelium of
kidneykidney tubulestubules)),,
 h)h) complicated pregnancy (accumulation of toxic matters),complicated pregnancy (accumulation of toxic matters),
 f)f) stress which is reason of:stress which is reason of:
- increase break up of glycogen in a depot- increase break up of glycogen in a depot
- increase of glyconeogenesis- increase of glyconeogenesis
- increase of products of glucocorticoids, which block glucokinase.- increase of products of glucocorticoids, which block glucokinase.

26. Reabsorption of the Amino AcidsReabsorption of the Amino Acids
 Amino acids filtered at the glomerulus are actively reabsorbedAmino acids filtered at the glomerulus are actively reabsorbed
in the proximal tubule. All reabsorption of amino acids isin the proximal tubule. All reabsorption of amino acids is
carrier-mediated.carrier-mediated.
 The TmThe Tm ((transport maximumtransport maximum)) for the carriers is well above thefor the carriers is well above the
amounts of amino acids normally filtered, so none areamounts of amino acids normally filtered, so none are
normally present in the urine.normally present in the urine.
Reabsorption of Plasma ProteinsReabsorption of Plasma Proteins
 Very few plasma proteins are filtered across the glomerulus.Very few plasma proteins are filtered across the glomerulus.
Those that are filtered are actively reabsorbed across theThose that are filtered are actively reabsorbed across the
proximal tubule. Because the GFR is so high, the filtration ofproximal tubule. Because the GFR is so high, the filtration of
even a few molecules of plasma protein, such aseven a few molecules of plasma protein, such as albuminalbumin,,
would result in a significant daily loss of protein ifwould result in a significant daily loss of protein if
reabsorption did not occurreabsorption did not occur..
 The few proteins filtered at the glomerulus are notThe few proteins filtered at the glomerulus are not
reabsorbed. They are degraded by tubular cells and excretedreabsorbed. They are degraded by tubular cells and excreted
in the urine.in the urine.
 ExamplesExamples of these proteins include the protein hormones,of these proteins include the protein hormones,
such as growth hormone and luteinizing hormone, both ofsuch as growth hormone and luteinizing hormone, both of
which are secreted from the anterior pituitary.which are secreted from the anterior pituitary.

27.  30 mg% of albumins is a normal concentration in primary urine, in30 mg% of albumins is a normal concentration in primary urine, in
secondary urine of proteins are absent, because albumins fullysecondary urine of proteins are absent, because albumins fully
absorption in kidneyabsorption in kidney tubulestubules..
 The presence of albumines in the second urine is calledThe presence of albumines in the second urine is called proteinuriaproteinuria..
Types of proteinuria:Types of proteinuria:
1) functional: a) alimentary, b) during march1) functional: a) alimentary, b) during march
2) organic: a) extrarenal and b) renal.2) organic: a) extrarenal and b) renal.
a)a) ExtrarenalExtrarenal is observed at inflammatory processes in urinary tractsis observed at inflammatory processes in urinary tracts
b)b) RenalRenal proteinuria arises up as a result:proteinuria arises up as a result:
 - increasing permeability of glomerular filter (glomerular proteinuria).- increasing permeability of glomerular filter (glomerular proteinuria).
Reasons are:Reasons are:
a)a) acute and chronic glomerulonephritis),acute and chronic glomerulonephritis),
b)b) infectious and toxic damages of kidneys,infectious and toxic damages of kidneys,
c)c) heart failure;heart failure;
 - decreasing of tubular- decreasing of tubular reabsorptionreabsorption of albumen (tubular proteinuria) –of albumen (tubular proteinuria) –
nephrosis,tubulopathynephrosis,tubulopathy
 - secretory proteinuria pathological entering of albumen from the- secretory proteinuria pathological entering of albumen from the
damaged cells of tubular epithelium or from lymphatic liquiddamaged cells of tubular epithelium or from lymphatic liquid
 ProteinuriaProteinuria can becan be
 a) selective, when low-molecular proteins are determined in urine only, b)a) selective, when low-molecular proteins are determined in urine only, b)
unselective, for which characteristic appearance in urine both low- andunselective, for which characteristic appearance in urine both low- and
high-molecular proteins.high-molecular proteins.
 The loss of albumen conducts to hypoproteinemia, decreasing of oncoticThe loss of albumen conducts to hypoproteinemia, decreasing of oncotic
pressure and to development of edema.pressure and to development of edema.

28.  Violation ofViolation of reabsorptionreabsorption of water and concentration ability of kidneysof water and concentration ability of kidneys..
 Specific gravity of primary urine is 1.010. It is equal to plasma of blood.Specific gravity of primary urine is 1.010. It is equal to plasma of blood. LossLoss
of concentration abilityof concentration ability is calledis called hypostenuriahypostenuria, relative, relative density aqualdensity aqual
inin state changes within the limit of 1,006-1,012 (normstate changes within the limit of 1,006-1,012 (normaa – 1,002-– 1,002-
1,035). If1,035). If density urinedensity urine is kept at 1,010is kept at 1,010 level and is not changedlevel and is not changed
withwith influence water load, itinfluence water load, it is calledis called isostenuriaisostenuria (monotone(monotone diuresisdiuresis))
 RReabsorptioneabsorption of water (obligatory) takes place in proximal convolutedof water (obligatory) takes place in proximal convoluted tubulestubules
and descending part of loop of Henle (about 75-80% primary filtrates).and descending part of loop of Henle (about 75-80% primary filtrates).
Hypertonic urine appears.Hypertonic urine appears.
 In ascending part of loop of Henle of Na+ mainly resorb as result urine becomeIn ascending part of loop of Henle of Na+ mainly resorb as result urine become
hypotonic. There is optionalhypotonic. There is optional reabsorptionreabsorption of water (depends on maintenance ofof water (depends on maintenance of
water and Na+ in blood) in distal convolutedwater and Na+ in blood) in distal convoluted tubulestubules, so urine becomes, so urine becomes
hypertonic again. This system of kydneys to excrete urine in 4 times morehypertonic again. This system of kydneys to excrete urine in 4 times more
hypertonic and in 6 times hypotonic from plasma of blood.hypertonic and in 6 times hypotonic from plasma of blood.
 Reasons of decreasing ofReasons of decreasing of reabsorptionreabsorption of water:of water:
 -- violation of the hormonal regulationviolation of the hormonal regulation (decreasing of aldosterone and(decreasing of aldosterone and
vasopressin, as result diabetes insipidus appears)vasopressin, as result diabetes insipidus appears)
 -- insufficiency of aquapurins 1, 2, 3insufficiency of aquapurins 1, 2, 3 – the integrated membrane proteins, which– the integrated membrane proteins, which
form the water channels,form the water channels,
 -- denervation of kidneysdenervation of kidneys
 - introduction to the organism of adrenoblockers- introduction to the organism of adrenoblockers
 - inflammatory and dystrophic changes of epithelium of- inflammatory and dystrophic changes of epithelium of tubulestubules
 - increase in primary urine- increase in primary urine of maintenance of matters which stipulate itsof maintenance of matters which stipulate its
osmotic concentration (glucose, urea and other).osmotic concentration (glucose, urea and other).

29.  The inorganic phosphate and calcium
disorder reabsorbtion have the hereditary
character.
 Renal phosphate diabetes is manifested with
phosphaturia, calciuria, rachitis, resistance to
vitamin D, canalicules sensitiviby to parathormone
increase (pseudohyperparathyroidism).
 Hereditary osteodystrophias are characterized
with hypocalciemia, hypophosphatemia,
parathormone canalicules resistance because of
appropriate receptors absence
(pseudohyperparathyroidism)

30.  Substances, which secreted by kidneys are:
a) hydrogen ions (regulation of acid-base balance),
b) urea, urinary acid, kreatine, creatinine, toxic matters,
c) medicinal preparations (separate sulfanilamids and antibiotics),
d) roentgen contrasting matters.
 Principal reason of violation of tubular secretion is a
damage of epithelium of tubules, especially, distal part
which is observed at:
a) toxic, metabolic and infectious influencing,
b) at the action of physical factors (ionizing a radiation).
 Violation of glomerular filtration, tubular reabsorption and
tubular secretion is reason of origin of urinary syndrome –
quantitative and high-quality changes of urine.
 Disorder of theDisorder of the canaliculescanalicules functionfunction is called as tubulartubular
insufficiencyinsufficiency
 It can be hereditary orhereditary or acquiredacquired
 The selective disorders reabsorption of separate ultrafiltrate
components are convenient to separate considering
Violation of tubular secretionViolation of tubular secretion

31. Combined tubulopathia.Combined tubulopathia.
 TThe most known exahe most known exammple ofple of ssuchuch disorders isdisorders is
thethe FankonyFankony syndrome.syndrome.
 In basisIn basis ofof thisthis symptomocomplexsymptomocomplex lies kidneyslies kidneys
canaliculescanalicules functionfunction generalizedgeneralized disorder.disorder.
 ItIt includesincludes glucosuria, aminoaciduria,glucosuria, aminoaciduria,
phosphaturia, hypercalciuria,hypernatriuria,phosphaturia, hypercalciuria,hypernatriuria,
proteinuria, proximal renal canalicules acidosisproteinuria, proximal renal canalicules acidosis
withwith bicarbonaturia, rachitis with resistantionbicarbonaturia, rachitis with resistantion toto
vitamin D.vitamin D.
Disoder of secretionDisoder of secretion
 The main mThe main manifestationanifestation – c– canaliculus acidosisanaliculus acidosis;;
amammmonium- and acidogenesisonium- and acidogenesis inhibitioninhibition andand
secretion H+-ions lsecretion H+-ions lieiess it isit is basis.basis.
 HHyperuricemia, which develops owing toyperuricemia, which develops owing to urinaryurinary
acid secretionacid secretion disorderdisorder and lead toand lead to gout (renalgout (renal
form).form).
 KKidneys functionsidneys functions disordersdisorders of can be completedof can be completed
withwith their insufficiencytheir insufficiency..

32. Changes of obligatory diuresisChanges of obligatory diuresis
OliguriaOliguria is decreasing of diuresis below 700 (500) ml per day.is decreasing of diuresis below 700 (500) ml per day.
AnuriaAnuria is complete absence of diuresis or lesser than 50 ml per day.is complete absence of diuresis or lesser than 50 ml per day.
• Distinguish the followings types of oligo- and anuria:Distinguish the followings types of oligo- and anuria:
• a)a) prerenalprerenal – at violation of blood supply of kidneys (shock, collapse,– at violation of blood supply of kidneys (shock, collapse,
thrombosis of kidney arteries);thrombosis of kidney arteries);
• b) renal - related to decreasing ofb) renal - related to decreasing of glomerularglomerular filtration and increasing offiltration and increasing of
tubulartubular reabsorptionreabsorption of water and electrolytes (during the surplusof water and electrolytes (during the surplus
selection of aldosterone and vasopressin);selection of aldosterone and vasopressin);
• c)c) subrenalsubrenal is violation of outflow of urine (blocking urinary tracts by ais violation of outflow of urine (blocking urinary tracts by a
stone, tumor);stone, tumor);
• d)d) reflexive-renalreflexive-renal – at annoying the receptors of one kidney (for– at annoying the receptors of one kidney (for
example by a stone), after renalexample by a stone), after renal--renal reflex there is a spasm of vesselsrenal reflex there is a spasm of vessels
of the second kidney and a selection urine is halted;of the second kidney and a selection urine is halted;
• e)e) reflexive-peripheralreflexive-peripheral – at annoying the of different receptors lead to– at annoying the of different receptors lead to
spasm of kidney arteries (cold water and irritancies receptors of skin,spasm of kidney arteries (cold water and irritancies receptors of skin,
annoying the pain receptors of abdominal region);annoying the pain receptors of abdominal region);
• f)f) traumatictraumatic – arises up at a crush [compression, Bywaters'] syndrome,– arises up at a crush [compression, Bywaters'] syndrome,
which conduces to the obstruction of filter of kidney by myoglobin;which conduces to the obstruction of filter of kidney by myoglobin;
• g)g) hemolytichemolytic - arises up at massive hemolysis of erythrocytes, which- arises up at massive hemolysis of erythrocytes, which
conduces to the obstruction of filter of kidney by hemoglobin.conduces to the obstruction of filter of kidney by hemoglobin.

33. Consequences of olyguria (anuria)Consequences of olyguria (anuria)
are:are:
a) increasing the volume of
extracellular liquid – hyperhydrationhyperhydration;
b) accumulating osmotic active
matters in an organism –
hypernatremia, hyperkalemiahypernatremia, hyperkalemia
[hyperpotassemia];
c) accumulating of the ending
products of metabolism in blood –
azotemiaazotemia [uremia].

34. PoliuriaPoliuria is increase of diuresis more thanis increase of diuresis more than
1,8 (2,0) liters per day.1,8 (2,0) liters per day.
In dependence on the mechanisms of developmentIn dependence on the mechanisms of development poliuriapoliuria select theselect the
followings kinds:followings kinds:
a)a) Aquatic diuresisAquatic diuresis conditioned by decreasing of facultativeconditioned by decreasing of facultative reabsorptionreabsorption
of water. Arise up:of water. Arise up:
- at the considerable aquatic loading (psychogenic polydipsia)- at the considerable aquatic loading (psychogenic polydipsia)
- at diabetes insipidus (insufficiency of vasopressin)- at diabetes insipidus (insufficiency of vasopressin)
At such polydipsia secreted approximately 15-18 l of urine. Urine isAt such polydipsia secreted approximately 15-18 l of urine. Urine is
hypooncotic, because contains few osmotic active matters.hypooncotic, because contains few osmotic active matters.
b)b) Osmotic diuresisOsmotic diuresis. Related to increasing maintenance in urine of. Related to increasing maintenance in urine of
unresorpted osmotic active matters, that led to disorders ofunresorpted osmotic active matters, that led to disorders of
reabsorption of water. Reasons:reabsorption of water. Reasons:
- violation of- violation of reabsorptionreabsorption of electrolytes;of electrolytes;
- multiplying maintenance in primary urine of the so-called thresholds- multiplying maintenance in primary urine of the so-called thresholds
matters (glucose at diabetes mellitus, hydrogen carbonates atmatters (glucose at diabetes mellitus, hydrogen carbonates at
alkalosis);alkalosis);
- actions of exogenous matters which badly resorbed (mannitol) or- actions of exogenous matters which badly resorbed (mannitol) or
violate reabsorption of electrolytes of Na+ and K+ (saluretic drugs).violate reabsorption of electrolytes of Na+ and K+ (saluretic drugs).
In the conditions of maximal osmotic polyuria the selection of urineIn the conditions of maximal osmotic polyuria the selection of urine
can achieve a 40% fromcan achieve a 40% from glomerularglomerular filtration (about 25 l per day).filtration (about 25 l per day).

35. Mechanisms of theMechanisms of the poliuriapoliuria development (cont)development (cont)
c)c) Hypertensive diuresisHypertensive diuresis. Develops at arterial. Develops at arterial
hypertension, when the rate of movement of blood ishypertension, when the rate of movement of blood is
multiplied in the direct vessels of cerebral layer ofmultiplied in the direct vessels of cerebral layer of
kidneys (these vessels go parallel the knees of loopkidneys (these vessels go parallel the knees of loop
of Henle). The convection transport is multiplied.of Henle). The convection transport is multiplied.
As result sodium, chlorine, urea is "washing" fromAs result sodium, chlorine, urea is "washing" from
interstitial tissue. It conduces to diminishing ofinterstitial tissue. It conduces to diminishing of
osmotic pressure of extracellular liquid, as a resultosmotic pressure of extracellular liquid, as a result
reabsorptionreabsorption of water diminishes in descending partof water diminishes in descending part
of loop of Henle andof loop of Henle and polyuriapolyuria develops.develops.
d)d) Compensate diuresisCompensate diuresis. It related to increase of. It related to increase of
concentration in blood of urea (at the initiallyconcentration in blood of urea (at the initially
shrunken [pursy] kidney), which stimulates healthyshrunken [pursy] kidney), which stimulates healthy
glomerulus and multiplies uropoiesis.glomerulus and multiplies uropoiesis.

36. NocturiaNocturia [nycturia] is a pathological sign,[nycturia] is a pathological sign,
when nightly part of diuresis more then daily.when nightly part of diuresis more then daily.
 In a norm 60-80% day's amount of urine selected in aIn a norm 60-80% day's amount of urine selected in a
period from 8 to 20 hour, that correlation nightly diuresis toperiod from 8 to 20 hour, that correlation nightly diuresis to
daily is 1:2.daily is 1:2.
 In dependence on reasons select following types:In dependence on reasons select following types:
 a)a) cardiac nycturiacardiac nycturia - develops at cardiac insufficiency. In the- develops at cardiac insufficiency. In the
day-timeday-time in connection heart failurein connection heart failure edema developsedema develops. At. At
nightnight in horizontal position a venous outflow is improvedin horizontal position a venous outflow is improved
and loading on a heart decreasing. It causes the selectionand loading on a heart decreasing. It causes the selection
of atrium hormone →of atrium hormone → increase diuresisincrease diuresis;;
 b)b) kidney nycturiakidney nycturia - characteristic for the damaged kidneys.- characteristic for the damaged kidneys.
It is explained by improvement of the broken kidney bloodIt is explained by improvement of the broken kidney blood
stream at night. As a result motion of blood is acceleratedstream at night. As a result motion of blood is accelerated
on the vessels of kidneys, hypertensive polyuria develops.on the vessels of kidneys, hypertensive polyuria develops.

37.  PolakyuriaPolakyuria is increasing of frequent of urinationis increasing of frequent of urination..
 Specific gravity of urine equals 1.016 – 1.020 for a healthySpecific gravity of urine equals 1.016 – 1.020 for a healthy
man at an ordinary diet.man at an ordinary diet. рНрН of urine equal 6,0.of urine equal 6,0.
 HypersthenuriaHypersthenuria is increasing specific gravity of urine moreis increasing specific gravity of urine more
than 1.028.than 1.028.
 HyposthenuriaHyposthenuria is decreasing specific gravity of urine lesseris decreasing specific gravity of urine lesser
then 1.012then 1.012
 Combination ofCombination of hypostenuria with polyuriahypostenuria with polyuria testifies to thetestifies to the
damage ofdamage of tubulestubules at relatively to the stored function ofat relatively to the stored function of
glomerulusglomerulus. If hypostenuria arises up on a background. If hypostenuria arises up on a background
olyguria, it is a sign of damage of all structures ofolyguria, it is a sign of damage of all structures of
nephrones (glomerulus andnephrones (glomerulus and tubulestubules).).
 At a complete loss by the kidneys of ability to concentrateAt a complete loss by the kidneys of ability to concentrate
and conduct urineand conduct urine isohyposthenuriaisohyposthenuria develops. Itsdevelops. Its
characterized by stability of specific gravity per day, but itcharacterized by stability of specific gravity per day, but it
index equal primary filtrate (1.010).index equal primary filtrate (1.010).
 IsosthenuriaIsosthenuria is the sign of heavy structurally functionalis the sign of heavy structurally functional
violations of kidneys.violations of kidneys.

38. Thus, there are the followings high-Thus, there are the followings high-
quality changes of urine at kidneyquality changes of urine at kidney
insufficiency:insufficiency:
• 1) Proteinuria is a selection of albumen with urine.
• 2) Hematuria is appearance of erythrocytes in urine. Reasons:
a) damage of glomerulus. The "lixiviated" erythrocytes are determined in
urine;
b) damage of urinary tracts.
• 3) Hemoglobinuria is a presence of Hb in urine.
• 4) Cylindruria is appearance in urine of cylinders. Cylinders show by
itself molds of kidney tubules. They will appear at the damage of
epithelium of tubules and consist of coagulative albumen and lost cells
(leucocytes and epytheliocytes). In dependence on a structure
distinguish hyaline, grainy [granular], cereous, lipoid, leukocyte and
epitheliums cylinders.
• 5) Lekocyteuria is appearance in urine of leucocytes over 5 in eyeshot.
Pyuria is the state, when the amount of lekocytes in eyeshot is more
than 100 cells. Principal reason of leukocyteuria is inflammatory
processesprocesses in kidneys and urinary tracts.
•6) Crystalluria in a surplus amount: a) crystals of urinary acid as
yellow, b) oxalate, c) urates, d) phosphates, e) crystals of oxalic
calcium, f) crystals of cystine crystals of tyrosine, g) crystals of
cholesterol.

39. AzotemiaAzotemia
 AzotemiaAzotemia refers to abnormal elevation of nitrogenous wasterefers to abnormal elevation of nitrogenous waste
products in the blood such as urea, uric acid, and creatinine.products in the blood such as urea, uric acid, and creatinine.
 Azotemia indicates a decrease in GFR, occurring either acutelyAzotemia indicates a decrease in GFR, occurring either acutely
or with chronic renal failure.or with chronic renal failure.
 Azotemia is an early sign of renal damage.Azotemia is an early sign of renal damage.
UremiaUremia
 UremiaUremia is not a single event, but rather a syndrome (ais not a single event, but rather a syndrome (a
constellation of symptoms) that develops in an individual whoconstellation of symptoms) that develops in an individual who
has end-stage renal disease. Because the kidney is pivotal inhas end-stage renal disease. Because the kidney is pivotal in
maintaining water, acid-base, and electrolyte balance and inmaintaining water, acid-base, and electrolyte balance and in
removing toxic waste products, the symptoms of uremia areremoving toxic waste products, the symptoms of uremia are
widespread and affect all the organs and tissues of the body.widespread and affect all the organs and tissues of the body.
 Common symptoms include fatigue, anorexia, nausea,Common symptoms include fatigue, anorexia, nausea,
vomiting, and lethargy. Intractable itching (pruritus) may occur.vomiting, and lethargy. Intractable itching (pruritus) may occur.
Hypertension, osteodystrophy, and uremic encephalopathyHypertension, osteodystrophy, and uremic encephalopathy
develop as well, with central nervous system changes,develop as well, with central nervous system changes,
including confusion and psychosis, characterizing end stages.including confusion and psychosis, characterizing end stages.
 The range of symptoms appears to be caused by acidosis,The range of symptoms appears to be caused by acidosis,
anemia from decreased erythropoietin, and the buildup of allanemia from decreased erythropoietin, and the buildup of all
waste products.waste products.

40. AnasarcaAnasarca
• Defined as a generalized edemageneralized edema in
individuals suffering from hypoalbuminemia
as a result of nephrotic syndrome or other
conditions, anasarca is caused by a systemic
decrease in capillary osmotic pressure.
• With a decrease in this major force favoring
reabsorption of interstitial fluid back into the
capillaries, edema of the interstitial space
throughout the body occurs.
• The edema is usually soft and pitting and
occurs early in the periorbital (surrounding
the eye) regions, the ankles, and the feet.

41. EDEMAEDEMA

42. The Major Renal Syndromes:
 Acute nephritic syndrome is a glomerular syndrome
dominated by the acute onset of usually grossly visible
hematuria (red blood cells in urine), mild to moderate
proteinuria, azotemia, edema, and hypertension; it is the classic
presentation of acute poststreptococcal glomerulonephritis.
 The nephrotic syndrome is a glomerular syndrome
characterized by heavy proteinuria (excretion of >3.5 gm of
protein/day in adults), hypoalbuminemia, severe edema,
hyperlipidemia, and lipiduria (lipid in the urine).
 Asymptomatic hematuria or proteinuria, or a combination of
these two, is usually a manifestation of subtle or mild glomerular
abnormalities.
 Rapidly progressive glomerulonephritis results in loss of
renal function in a few days or weeks and is manifested by
microscopic hematuria, dysmorphic red blood cells and red
blood cell casts in the urine sediment, and mild-to-moderate
proteinuria.

43. The Major Renal Syndromes:
 Acute renal failure is dominated by oliguria or anuria (no
urine flow), with recent onset of azotemia. It can result
from glomerular injury (such as crescentic
glomerulonephritis), interstitial injury, vascular injury (such
as thrombotic microangiopathy), or acute tubular
necrosis.
 Chronic renal failure, characterized by prolonged
symptoms and signs of uremia, is the end result of all
chronic renal diseases.
 Urinary tract infection is characterized by bacteriuria
and pyuria (bacteria and leukocytes in the urine). The
infection may be symptomatic or asymptomatic, and it
may affect the kidney (pyelonephritis) or the bladder
(cystitis) only.
 Nephrolithiasis (renal stones) is manifested by renal
colic, hematuria, and recurrent stone formation.

45. Acute renal insufficiencyAcute renal insufficiency
(ARI)(ARI) It is a clinical syndromeIt is a clinical syndrome ofof various ethiologyvarious ethiology ((ARIARI)), which, which
isis characterized by significant andcharacterized by significant and acuteacute decrease ofdecrease of
glomerulglomerular filtration speedar filtration speed ((GFSGFS))
 NormalNormal GFGFSS significancesignificance –– 100-140 ml/mines100-140 ml/mines
 Acute renalAcute renal insufficiencyinsufficiency develops, whendevelops, when GFGFSS is reducedis reduced
toto 1-10 ml/mines1-10 ml/mines
 Osmotic activeOsmotic active substancessubstances amountamount isis derivatedderivated which iswhich is
easily excrete ineasily excrete in volumevolume water ofwater of 1,5-2 l (daily diuresis1,5-2 l (daily diuresis))
for one day with, thefor one day with, the normal diet and normal metabolismnormal diet and normal metabolism
out ofout of organismorganism
 The minimum quantityThe minimum quantity ofof liquid, from which they can stillliquid, from which they can still
be excretedbe excreted makesmakes 500 ml500 ml
 AAcutecute renalrenal insufficiencyinsufficiency isis characterizedcharacterized byby suchsuch
disorderdisorder renalrenal functionsfunctions whenwhen diuresisdiuresis is reduced tois reduced to 500500
mlml.. This stateThis state is called asis called as oliguriaoliguria
 If dailyIf daily urineurine does not exceeddoes not exceed 100 ml,100 ml, takes placetakes place anuriaanuria

46. • The acute renal insufficiency reasons
are divided into three groups –
prerenal, renal and postrenal
• Prerenal factors include: circulating
liquid decrease (traumatic shock,
blood loss, burns, vomiting, diarrhea),
dilatation of vessels and vessels
capacity increase (sepsis,
anaphylaxia), heart insufficiency
(infarction of myocardium)

47. • Renal factors include:Renal factors include:
- ischemia kidneys,
- action nephrotoxical (antibiotics, heavy
metals, organic solvents, X-ray contrast
substances),
- intravessels erythrocytes hemolysis,
- glomerulonephritis,
- states assosiated to pregnancy (septic
abortion, eclampsia in pregnant, bleeding)

48.  PostrenalPostrenal factors include:factors include:
 UUretersreters oobstruction uretersbstruction ureters (canaliculus(canaliculus,,
bloodblood clots, tumor)clots, tumor) and urinal channeland urinal channel
obstruction (prostat hypertrophy, carcinoma)obstruction (prostat hypertrophy, carcinoma)..
 Postrenal reasonPostrenal reasonss of diuresisof diuresis decreasedecrease
are reducedare reduced ofof urineurine outflowoutflow due todue to obstacleobstacle
any levelany level ofof urinaryurinary wayway..
 Pathophysiological mechanismsPathophysiological mechanisms, which, which act inact in
acute renalacute renal insufficiencyinsufficiency are caused moreare caused more
complicatedcomplicated and can not beand can not be put into commonput into common
universal mechanism.universal mechanism.

49.  There areThere are four clinical phasesfour clinical phases of ARI.of ARI.
 Initial phaseInitial phase – is a– is a periodperiod, which courses from, which courses from
lesion oflesion of kidneyskidneys untilluntill oliguria development.oliguria development.
It takesIt takes several hours (ischemia)several hours (ischemia) up to aboutup to about
oneone week (afterweek (after actionaction nephrotoxine)nephrotoxine)
 Oliguric phaseOliguric phase is characterized by acuteis characterized by acute
decrease of GFS. Itdecrease of GFS. It course lastcourse last several daysseveral days
up toup to several weeks (two weeksseveral weeks (two weeks inin average).average).
The patientsThe patients perishperish just in this phasejust in this phase
 Diuretic phaseDiuretic phase is characterized by gradualis characterized by gradual
increase ofincrease of urine volumeurine volume.. Phase of recoveryPhase of recovery ––
period, during which renal function completelyperiod, during which renal function completely
are restored, though easyare restored, though easy oror moderatemoderate GFSGFS
decreasedecrease can be savedcan be saved inin some patientssome patients
 AAcutecute renal insufficiencyrenal insufficiency isis accompanied byaccompanied by
highhigh deathdeath, data, data ischemic and traumaticischemic and traumatic formform
aboutabout 50-70 %50-70 % other formother form – about– about 10-35 %10-35 %

51. Renal medullary hypoxia
Renal arteriolar vasoconstriction
Delivery of sodium to macula densa
Ischemia-induced cytoskeletal
rearrangement in renal tubular cells
Loss of polarity, integration redistribution,
and loss of adhesion in renal tubular cells
Sloughing of viable renal tubular cells
Inappropriate adhesion and
Obstruction of renal tubules
Futher tubular damage
Acute renal failure
Complicating factors (NSAIDs,
mioglobin Precipitation, Bence Jones
proteins, hypovolemia, sepsis
Irreversible renal failureRenal tubular regulation
IGF-1 and other protective factors
Release of prostaglandins,
adenosine, nitric oxide
Transport in medullary
thick ascending limb of
renal tubules
Medullary
blood flow
 Renal function
Medullary oxygen sufficiency

52. ChronicChronicalal renal insufficiency (renal insufficiency (CRICRI))
Symptoms chronical renal insufficiency develops in case GFS
25 % over norm
 The main reasons:The main reasons:
 primary glomerulus diseases
(chronic glomerulonephritis)
 the primary canaliculus diseases
(chronic pielonephritis tuberculosis)
 vascular diseases
(hypertonic illness, thrombosis, embolism)
 diffuse connective tissue diseases
(sclerodermia, nodular periarteriitis)
 illness metabolism (gout, diabetes mellitus),
 obstructive nephropathia (urolithiasis, hydronephrosis),
 hereditary anomalies (kidneys polycystic)

53. Renal functions decrease occurs due to
decrease of functiononal amount of active
nephrons
• The initial chronical renal insufficincy
signs occur owing to mass of acting
nephrons decrease to 50-30%50-30%
• The expressed clinic develops due to
acting nephrons decrease down to 30-10%30-10%
• Further acting nephrons weight decrease (is
lower than 10%lower than 10%)) results in terminal kidneys
insufficiency stage – uremiauremia

54. • Chronic renal failure: 4 stages
• I) ↓ renal reserve: GFR ~ 50% normal
BUN & creatinine normal, pt.
asymptomatic, more susceptible to
develop azotemia
• II) renal insufficiency: GFR 20-50% of
normal, azotemia, anemia, ↑ BP,
polyuria/nocturia (via ↓ concentrating
ability)
• III) renal failure: GFR less than 20-
25% kidneys cannot regulate volume,
ions: edema, hypocalcemia, metabolic
acidosis, uremia with neurological, CV
and GI complications
• IV) end stage renal disease: GFR < 5%
of normal, terminal stage of uremia

55.  Anemia – is obviously the most characteristic sign of
chronical renal insufficiency.
 The main factor, which cause it is development is lowering of
erythropoitin. It’s also important that degree hemolys is
increased, which shortens erythrocytes life duration.
 Uremia, besides oppress bone marrow ability to erythropoietin
reaction, and because even due to it enough amount bone
marrow response is not adequate.
 The chronical renal insufficiency in patient an alimentary
channel bleeding is anusual state. Continuous loss blood
result in deficiency iron, which promotes anemia development.
 Chronical renal insufficiency in the patients have a
qualitative changes of thrombocytes (thrombocylopathy). It
appears as bleeding duration increase. Thrombocytes function
gets oppressed with guanidinic and oxyphenilacetic acids.

56. HeartHeart is damaged owing to hypertension. The combinationis damaged owing to hypertension. The combination
of hypertension, anemia,of hypertension, anemia, liquidliquid overloadingoverloading and acidosisand acidosis
promotespromotes heartheart insufficiencyinsufficiency development.development. IInn half ofhalf of
patients chronical renal terminal insufficiencypatients chronical renal terminal insufficiency stagestage
pericarditis developspericarditis develops
TheThe lunglung damagedamage is performedis performed with so-called uremicwith so-called uremic
pneumonitis, whichpneumonitis, which isis the stagnant phenomen in vessels ofthe stagnant phenomen in vessels of
peritrachealperitracheal
Arterial hypertensionArterial hypertension is observed in 50% ofis observed in 50% of terminalterminal
chronicalchronical renalrenal insufficiency stage.insufficiency stage. It arises is connected toIt arises is connected to
hyperproduction reninehyperproduction renine vasodilatative prostaglandinsvasodilatative prostaglandins,,
oppression limitationoppression limitation sodiumsodium excretionexcretion ofof extracellularextracellular liquidliquid
volumevolume increaseincrease
Gastrointestinal disorderGastrointestinal disorder – anorexia– anorexia, nausea, vomitis. The, nausea, vomitis. The
bleeding from alimentbleeding from alimentaary cry chhannelannel isis oftenoften
phenomenon.phenomenon.TheirTheir sourcesource are the smallare the small surfacesurface ulcers,ulcers,
which bleedwhich bleedinging slowlyslowly

57. OsteodistrophyOsteodistrophy, which arises according to
mentioned above changes, includes such
disorders:
а) ffibrosis-cystosesibrosis-cystoses osteitis as result of
secondary hyperparathyreosis; it appears
subperiosteol bone resorbtion;
b) oosteomalationsteomalation – bones defeat which
organic matrix mineralisation process
mineralisation infringed;
c) oosteosclerosissteosclerosis – bone density increase;
d) oosteoporosissteoporosis – bone weight
decrease and microstructural, which increase
bone fragility.

58.  Uremic encephalopathyUremic encephalopathy appearsappears withwith
sleepiness, inability to concentrationsleepiness, inability to concentration,, absent-absent-
mindness, and thenmindness, and then – amnesia– amnesia, hallutinations,, hallutinations,
delirium,delirium, crampscramps
 These bones change are capable to renderThese bones change are capable to render
destructivedestructive actionaction on organismon organism
 DelayDelay growthgrowth in childrenin children inin adultadult bonesbones delaydelay
pain fractures, compression vertexpain fractures, compression vertex os femorisos femoris
head, necrosis anhead, necrosis andd skskeeleton deformationleton deformation
 Arterial medial layerArterial medial layer calcificationcalcification can becan be
observedobserved withwith ischemicischemic necrosisnecrosis soft tissue skinsoft tissue skin
calcification with intolerable itch, periarteriitiscalcification with intolerable itch, periarteriitis
owing toowing to calciumcalcium oxyapatitis precipitation,oxyapatitis precipitation,
calcificationcalcification

59. UremiaUremia
 UremiaUremia is ais a term, which is usedterm, which is used for chronicalfor chronical
renal insufficiency terminal phaserenal insufficiency terminal phase
descriptiondescription. The majority of symptoms. The majority of symptoms
become well expressedbecome well expressed in GFS ratio belowin GFS ratio below
thanthan 1010 ml/min.ml/min.
 UUremic syndromeremic syndrome pathogenesis has becomepathogenesis has become
subject of intensive learningsubject of intensive learning for a long timefor a long time..
The numerous attempts were made toThe numerous attempts were made to
identify substances, which are accumulatedidentify substances, which are accumulated
inin renal insufficiency terminal phase andrenal insufficiency terminal phase and
reach dangerous to the vital function data.reach dangerous to the vital function data.

64. DISORDERS OF GLOMERULARDISORDERS OF GLOMERULAR
FUNCTIONFUNCTION

65. Two main mechanisms of damage of the glomeruli.Two main mechanisms of damage of the glomeruli.
 1.1. Affection of the basal membrane of theAffection of the basal membrane of the
glomeruli of the nephrons by antibodies itsglomeruli of the nephrons by antibodies its
antigens - nephrotoxic glomerulonephritis (itantigens - nephrotoxic glomerulonephritis (it
has a quick progressive course). Glycoproteinhas a quick progressive course). Glycoprotein
as a carrier of antigenic proteins of the basalas a carrier of antigenic proteins of the basal
membrane.membrane.
 2.2. Development of the inflammatory process inDevelopment of the inflammatory process in
the glomeruli due to fixation of the immunethe glomeruli due to fixation of the immune
complexes on the basal membranecomplexes on the basal membrane
-immunocomplex glomerulonephritis.-immunocomplex glomerulonephritis.

66. Disorders resulting in glomerular disease,Disorders resulting in glomerular disease,
whether manifestations of systemic injurywhether manifestations of systemic injury
or otherwise, fall into five categories:or otherwise, fall into five categories:
• 1. Acute glomerulonephritis, in which there is an abrupt onset of hematuria
and proteinuria with reduced GFR and renal salt and water retention, sometimes
followed by recovery of renal function. Patients with acute glomerulonephritis are
a subset of those with an intrarenal cause of acute kidney injury.
• 2. Rapidly progressive glomerulonephritis, in which recovery from the
acute disorder does not occur. Worsening renal function results in irreversible and
complete renal failure over weeks to months. Early in the course of rapidly
progressive glomerulonephritis, these patients can be categorized as having a
form of acute kidney injury. Later, with progression of their renal failure over time,
they display all of the features described for chronic renal failure.
• 3. Chronic glomerulonephritis, in which renal impairment after acute
glomerulonephritis progresses slowly over a period of years and eventually
results in chronic renal failure.
• 4. Nephrotic syndrome, manifested as marked proteinuria, particularly
albuminuria (defined as 24-hour urine protein excretion > 3.5 g),
hypoalbuminemia, edema, hyperlipidemia, and fat bodies in the urine. Nephrotic
syndrome may be either isolated (eg, minimal change disease) or part of some
other glomerular syndrome (eg, with hematuria and casts).
• 5. Asymptomatic urinary abnormalities, including hematuria and proteinuria
(usually in amounts below that seen in nephrotic syndrome) but no functional
abnormalities associated with reduced GFR, edema, or hypertension. Many
patients with these findings will develop chronic renal failure slowly over decades.

68. PATHOGENESIS
• Antibodies against inherent GBM
• Antibodies against “planted” antigens
• Trapping of Ag-Ab complexes
• Antibodies against glomerular cells, e.g.,
mesangial cells, podocytes, etc.
• Cell mediated immunity, i.e., sensitized T-
cells as in TB

69. Pathogenesis of GlomerularPathogenesis of Glomerular
Disease/InjuryDisease/Injury
• Little is known regarding etiology orLittle is known regarding etiology or
triggeringtriggering
• Immune mechanisms underlie mostImmune mechanisms underlie most
cases of primary GN and many of thecases of primary GN and many of the
secondary casessecondary cases
a) 2 forms of Ab-associated injury
I) injury resulting from soluble Ag-Ab
deposits in glomerulus
II) injury from Ab reacting in-situ with
glomerulus
- insoluble fixed glomerular Ag
- molecules planted w/in

70. IgA NEPHROPATHYIgA NEPHROPATHY
(BERGER DISEASE)(BERGER DISEASE)
 Mild hematuriaMild hematuria
 Mild proteinuriaMild proteinuria
 IgA deposits in mesangiumIgA deposits in mesangium

71. HEREDITARY HEMATURIAHEREDITARY HEMATURIA
SYNDROMESSYNDROMES
• ALPORT SYNDROMEALPORT SYNDROME
– Progressive Renal FailureProgressive Renal Failure
– Nerve DeafnessNerve Deafness
– VARIOUS eye disorderVARIOUS eye disorder
– DEFECTIVE COLLAGEN TYPE IVDEFECTIVE COLLAGEN TYPE IV
• THIN GBM (Glomerular Basement Membrane)THIN GBM (Glomerular Basement Membrane)
Disease, i.e., about HALF as uniformly thin as itDisease, i.e., about HALF as uniformly thin as it
should beshould be

73. The Nephrotic SyndromeThe Nephrotic Syndrome
 The The nephrotic syndromenephrotic syndrome is characterized by proteinuria, which results in is characterized by proteinuria, which results in
hypoalbuminemia and edema.Podocyte injury is an underlying mechanism hypoalbuminemia and edema.Podocyte injury is an underlying mechanism
of proteinuria, and may be the result of nonimmune causes (as in MCD and of proteinuria, and may be the result of nonimmune causes (as in MCD and
FSGS) or immune mechanisms (as in MN).FSGS) or immune mechanisms (as in MN).
 MMnimal change disease (MCD)nimal change disease (MCD) is the most frequent cause of nephrotic is the most frequent cause of nephrotic
syndrome in children; syndrome in children;
- - it is manifested by proteinuria and effacement of glomerular foot processes it is manifested by proteinuria and effacement of glomerular foot processes
without antibody deposits; without antibody deposits;
- - the pathogenesis is unknown; the disease responds well to steroid therapy.the pathogenesis is unknown; the disease responds well to steroid therapy.
 Focal and segmental glomerulosclerosis (FSGS)Focal and segmental glomerulosclerosis (FSGS) may be primary (podocyte may be primary (podocyte
injury by unknown mechanisms) or secondary (e.g. as a consequence of injury by unknown mechanisms) or secondary (e.g. as a consequence of
prior glomerulonephritis, hypertension or infection such as HIV); prior glomerulonephritis, hypertension or infection such as HIV);
- - glomeruli show focal obliteration of capillary lumens, hyaline deposits and glomeruli show focal obliteration of capillary lumens, hyaline deposits and
loss of foot processes; loss of foot processes;
- - the disease is often resistant to therapy and may progress to end stage renal the disease is often resistant to therapy and may progress to end stage renal
diseasedisease
 Membranous nephropathy (MN)Membranous nephropathy (MN) is caused by an autoimmune response is caused by an autoimmune response
against an unknown renal antigen; against an unknown renal antigen;
- - it is characterized by granular subepithelial deposits of antibodies with GBM it is characterized by granular subepithelial deposits of antibodies with GBM
thickening and loss of foot processes but little or no inflammation; thickening and loss of foot processes but little or no inflammation;
- t- the disease is often resistant to steroid therapy. he disease is often resistant to steroid therapy.

74. The Nephritic SyndromeThe Nephritic Syndrome
 The The nephritic syndromenephritic syndrome is characterized by hematuria, oliguria with is characterized by hematuria, oliguria with
azotemia, proteinuria, and hypertension.azotemia, proteinuria, and hypertension.
 The most common causes are immunologically mediated glomerular injury; The most common causes are immunologically mediated glomerular injury;
- - lesions are characterized by proliferative changes and leukocyte infiltration.lesions are characterized by proliferative changes and leukocyte infiltration.
 Acute post-infectious glomerulonephritisAcute post-infectious glomerulonephritis typically occurs after streptococcal typically occurs after streptococcal
infection in children and young adults but may occur following infection with infection in children and young adults but may occur following infection with
many other organisms; many other organisms;
- - it is caused by deposition of immune complexes mainly in the subepithelial it is caused by deposition of immune complexes mainly in the subepithelial
spaces, with abundant neutrophils and proliferation of glomerular cells. spaces, with abundant neutrophils and proliferation of glomerular cells.
 Most affected children recover; the prognosis is worse in adults.Most affected children recover; the prognosis is worse in adults.
 IgA nephropathyIgA nephropathy,, characterized by mesangial deposits of IgA-containing characterized by mesangial deposits of IgA-containing
immune complexes, is the most common cause of the nephritic syndrome immune complexes, is the most common cause of the nephritic syndrome
worldwide; worldwide;
- - it is also a common cause of recurrent hematuria; it is also a common cause of recurrent hematuria;
- - it commonly affects children and young adults and has a variable course.it commonly affects children and young adults and has a variable course.
 Hereditary nephritisHereditary nephritis is caused by mutations in genes encoding GBM is caused by mutations in genes encoding GBM
collagen; collagen;
- it manifests as hematuria and slowly progressing poteinuria and declining it manifests as hematuria and slowly progressing poteinuria and declining
renal function; renal function;
- glomeruli appear normal until late in the disease course. glomeruli appear normal until late in the disease course.

75. OBSTRUCTIVE DISORDERSOBSTRUCTIVE DISORDERS
Level of Obstruction Cause
Renal pelvis
Renal calculi
Papillary necrosis
Ureter
• Renal calculi
• Pregnancy
• Tumors that compress the ureter
• Ureteral stricture
• Congenital disorders of the ureterovesical
junction and ureteropelvic junction strictures
Bladder and urethra
• Bladder cancer
• Neurogenic bladder
• Bladder stones
• Prostatic hyperplasia or cancer
• Urethral strictures
• Congenital urethral defects

76. Composition, Contributing Factors, andComposition, Contributing Factors, and
Treatment of Kidney StonesTreatment of Kidney Stones
Type of Stone Contributing Factors Treatment
Calcium (oxalate and
phosphate)
Hypercalcemia and hypercalciuria
Immobilization
Treatment of underlying conditions
Increased fluid intake
Thiazide diuretics
Magnesium ammonium
phosphate (struvite)
Hyperparathyroidism
Vitamin D intoxication
Diffuse bone disease
Milk-alkali syndrome
Renal tubular acidosis
Hyperoxaluria
Intestinal bypass surgery
Dietary restriction of foods high in
oxalate
Uric acid (urate) Urea-splitting urinary tract
infections
Treatment of urinary tract infection
Acidification of the urine
Increased fluid intake
Cystine Formed in acid urine with pH of
approximately 5.5
Gout
High-purine diet
Cystinuria (inherited disorder of
amino acid metabolism)
Increased fluid intake
Allopurinol for hyperuricuria
Alkalinization of urine
Increased fluid intake
Alkalinization of urine

77. Staghorn calculi. The kidney shows hydronephrosis and stonesStaghorn calculi. The kidney shows hydronephrosis and stones
that are casts of the dilated calyces.that are casts of the dilated calyces. (Rubin E., Farber J.L.(Rubin E., Farber J.L.
[1999].[1999]. PathologyPathology [3rd ed., p. 909]. Philadelphia: Lippincott[3rd ed., p. 909]. Philadelphia: Lippincott
Williams & Wilkins)Williams & Wilkins)
Hydronephrosis. Bilateral urinary tract obstruction has led to conspicuous
dilatation of the ureters, pelves, and calyces. The kidney on the right
shows severe cortical atrophy. (Rubin E., Farber J.L. [1999]. Pathology
[3rd ed., p. 910]. PhilaIndelphia: Lippincott Williams & Wilkins)

79. TransplantationTransplantation
Transplant tourismTransplant tourism
The Geneva-basedThe Geneva-based
WHO believes thatWHO believes that
"transplant tourism" is"transplant tourism" is
rising, as rich patientsrising, as rich patients
bypassed bans onbypassed bans on
buying organs at homebuying organs at home
by travelling abroad toby travelling abroad to
receive kidneys fromreceive kidneys from
poor donors.poor donors.
Beside kidneys alsoBeside kidneys also
trafficking of half-trafficking of half-
livers, eyes, skin andlivers, eyes, skin and
blood is flourishing.blood is flourishing.
((More e.g.More e.g. UPIUPIJan 12thJan 12th
20092009))

81. Literature:Literature:
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Jacquelyn L. Banasik // Elsevier Inc, 4th edition. – 2010. – P. 630–Jacquelyn L. Banasik // Elsevier Inc, 4th edition. – 2010. – P. 630–
719. 719.
2.2. Pathophysiology, Concepts of Altered Health States, Carol Mattson Pathophysiology, Concepts of Altered Health States, Carol Mattson
Porth, Glenn Matfin. – New York, Milwaukee. – 2009. – P. 826–893, Porth, Glenn Matfin. – New York, Milwaukee. – 2009. – P. 826–893,
949–974.949–974.
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558888..
4.4. Robbins and Cotran Pathologic Basis of Disease Robbins and Cotran Pathologic Basis of Disease 88th edition./ th edition./
Kumar, Abbas, FautoKumar, Abbas, Fauto. –. – 200 20077.. – Chapter 14. – P. 541 – Chapter 14. – P. 541––579.579.
5.5. Russell JRussell J.. Greene Greene.. Pathology and Therapeutics for Pharmacists. A Pathology and Therapeutics for Pharmacists. A
basis for clinical pharmacy practicebasis for clinical pharmacy practice / / Russell J Russell J.. Greene, Norman D Greene, Norman D..
Harris // Published by the Pharmaceutical Press An imprint of RPS Harris // Published by the Pharmaceutical Press An imprint of RPS
Publishing 1 Lambeth High Street, London SE1 7JN, UK 100 South Publishing 1 Lambeth High Street, London SE1 7JN, UK 100 South
Atkinson Road, Suite 200, Greyslake, IL 60030-7820, Atkinson Road, Suite 200, Greyslake, IL 60030-7820, 3rd edition, 3rd edition,
USAUSA. – 2008. – Chapter 14. – P. 869–941.. – 2008. – Chapter 14. – P. 869–941.
6.6. Essentials of Pathophysiology: Concepts of Altered Health States Essentials of Pathophysiology: Concepts of Altered Health States
(Lippincott Williams & Wilkins), Trade paperback (2003) (Lippincott Williams & Wilkins), Trade paperback (2003) // Carol Carol
Mattson Porth, Kathryn J. GaspardMattson Porth, Kathryn J. Gaspard. . – – ССhaptershapters 2 222-25. – -25. – PP. 4. 40101––
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Elizabeth J. – 3th edition. Copyright ВElizabeth J. – 3th edition. Copyright В. . – Lippincott Williams & – Lippincott Williams &
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