Renal and urinary systems

153 Pages·2012·9.292 MB·English

by  Timothy Jones, Robert Thomas

Renal and Urinary Systems
First and second edition authors:
Nisha Mirpuri
Pratiksha Patel
Shreelata Data
Third edition authors:
Robert Thomas
Bethany Stanley
4
th Edition
CRASH COURSE
SERIES EDITOR:
Dan Horton-Szar
BSc(Hons) MBBS(Hons) MRCGP
NorthgateMedicalPractice
Canterbury, Kent, UK
FACULTY ADVISOR:
Kevin Harris
MedicalDirector
Reader and HonoraryConsultant
John Walls Renal Unit
Leicester General Hospital
Leicester, UK
Renal and
Urinary Systems
Timothy Jones
MBChB (Hons)
Medical Student
University of Leicester Medical School
Leicester, UK
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2012
CommissioningEditor:JeremyBowes
DevelopmentEditor:CaroleMcMurray
ProjectManager:AndrewRiley
Designer:StewartLarking
IconIllustrations:GeoParkin
IllustrationManager:JenniferRose
Illustrator:Cactus
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Firstedition1998
Secondedition2003
Thirdedition2007
Fourthedition2012
ISBN:9780723436294
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Series editor foreword
TheCrashCourseserieswasfirstpublishedin1997andnow,15yearson,
wearestillgoingstrong.Medicineneverstandsstill,andtheworkofkeeping
thisseriesrelevantfortoday’sstudentsisanongoingprocess.Thesefourth
editionsbuildonthesuccessoftheprevioustitlesandincorporatenewand
revisedmaterial,tokeeptheseriesup-to-datewithcurrentguidelinesforbest
practice,andrecentdevelopmentsinmedicalresearchandpharmacology.
Wealwayslistentofeedbackfromourreaders,throughfocusgroupsand
studentreviewsoftheCrashCoursetitles.Forthefourtheditionswehave
completelyre-writtenourself-assessmentmaterialtokeepupwithtoday’s
single-bestanswerandextendedmatchingquestionformats.Theartworkand
layoutofthetitleshasalsobeenlargelyre-workedtomakeiteasieronthe
eyeduringlongsessionsofrevision.
Despitefullyrevisingthebookswitheachedition,weholdfasttotheprinciples
onwhichwefirstdevelopedtheseries.CrashCoursewillalwaysbringyouall
theinformationyouneedtoreviseincompact,manageablevolumesthatintegrate
basicmedicalscienceandclinicalpractice.Thebooksstillmaintainthebalance
betweenclarityandconciseness,andprovidesufficientdepthforthoseaiming
atdistinction.Theauthorsaremedicalstudentsandjuniordoctorswhohave
recentexperienceoftheexamsyouarenowfacing,andtheaccuracyofthe
materialischeckedbyateamoffacultyadvisorsfromacrosstheUK.
Iwishyouallthebestforyourfuturecareers!
Dr Dan Horton-Szar
SeriesEditor
v
Prefaces
Author preface
Thisbookwaswrittenwiththeaimofpresentingsubjectsthatarecomplexand
importantformedicalstudentsinaconciseandunderstandableway.Itfollowsthe
successfulapproachofpreviouseditions,beingwrittenbymedicalstudentsthus
pitchedatanappropriatelevelformybusypeers.
Fortheneweditionthecontenthasbeenreorganisedtoremovetheseparation
betweenclinicalandpre-clinicalsubjects.Thus,onewillnowreadaboutthe
physiologyofosmolalitycontrolalongsidehyponatraemiaandhypernatraemia.
Thishasremovedanelementofrepetitioninthetextandimmediatelyhighlights
therelevanceofthebasicmedicalscience.
Theselfassessmentsectionnowconsistsofsinglebestanswerandextended
matchingquestionstoreflectthetrendofexaminationatmedicalschooland
beyond.Ihopethatyoufindthebookusefulandinterestingandthatyouenjoy
usingitforlearningandrevision.
Tim Jones
Faculty advisor
Diseasesoftheurinarytracthavetraditionallybeenseenasachallengingsubjectfor
medicalstudents.ThisCrashCoursebooksetsouttoensurethesubjectmatter
ispresentedinalogicalandconcisewaymakingthesubjectmatterreadily
accessibletothestudent.AswithallCrashCoursebooks,thetextisauthored
byamedicalstudentwithexpertinputfromaFacultyAdvisor(cid:1)me(cid:1)andthe
serieseditor.
This4theditionofthisCrashCourse:RenalandUrinarySystemsbookhas
undergoneextensiverevision.Thetexthasbeenreorganisedtoensurethatthereis
integrationbetween‘preclinical’pathophysiologicalconceptsand‘clinical’
presentationsofdisease.Thisapproachwillprovidethestudentwithalogical
theoreticalbasisforsolvingthesortsofproblemsthatarecommonlyencounteredin
clinicalpractice.Atthesametimethetexthasbeenupdatedwithreferencetothe
latestinternationallyrecognizedclassificationsofbothchronickidneydisease
(CKD)andacutekidneyinjury(AKI).
Arevisedselfassessmentsectionisdesignedtoprovidethestudentwithabasison
whichtoensuretheyhaveawellgroundedunderstandingofthesubjectmatter(cid:1)
notonlytoensuretheyareadyfortheirexamsbutalsotostimulatethemto
continuewithself-directedlearning.
Kevin Harris
vi
Acknowledgements
IamverygratefultoDrKevinHarrisforhishelpandadvicethroughouttheproject.
ThankyoualsotothestaffatElsevier,particularlyCaroleMcMurrayforthe
encouragementintheproductionofthisedition.
Figurecredits
Figures2.2,2.6and5.5fromKoeppenBM,StantonB1996Renalphysiology,2nd
edn.MosbyYearBook
Figure3.21BerneRM,LevyMN1996Physiology,3rdedn.MosbyYearBook
Figure7.7adaptedfromO’Callaghan,TheKidneyataglance2001Blackwell
science.
Figure8.27redrawnwithpermissionfromLImpey,Obstetricsandgynaecology
1999.
Figures8.16,8.20,8.22and8.29fromWilliamsG,MallickNP1994Coloratlasof
renaldiseases,2ndedn.MosbyYearBook
Figures8.23and8.28fromLloyd-DavisRWetal1994Coloratlasofurology,2nd
edn.MosbyYearBook.
Figure8.30fromJohnsonRJ,FeehallyJ2000Comprehensivenephrology.Mosby
YearBook.
ThankstoDrDRickards,DrTONunanandMrRSColeforclinicalimages.
vii
Contents
Serieseditorforeword . . . . . . . . . . . . . . . v Urinarytractobstructionandurolithiasis. . 77
Prefaces . . . . . . . . . . . . . . . . . . . . . . vi Inflammationoftheurinarytract . . . . . 80
Acknowledgements. . . . . . . . . . . . . . . . . vii Disordersoftheprostate . . . . . . . . . 81
6. Neoplasiaandcystsoftheurinary
1. Organizationofthekidneys . . . . . . . . 1
system . . . . . . . . . . . . . . . . . 85
Overviewofthekidneyandurinarytract . . 1
Neoplasticdiseaseofthekidney. . . . . . 85
Generalorganizationofthekidneys. . . . . 2
Neoplasticdiseaseoftheureters
Developmentofthekidneys . . . . . . . . 7 andbladder . . . . . . . . . . . . . . 86
Congenitalabnormalitiesofthekidney . . . 8 Carcinomaoftheprostate . . . . . . . . 89
2. Theglomerulus . . . . . . . . . . . . . 11 Cysticdiseasesofthekidney . . . . . . . 90
Glomerularstructureandfunction. . . . . 11 7. Acutekidneyinjuryandchronickidney
Diseasesoftheglomerulus . . . . . . . . 16 disease . . . . . . . . . . . . . . . . . 93
Terminology. . . . . . . . . . . . . . . 93
3. Thetubulesandtheinterstitium . . . . . 25
Acutekidneyinjury. . . . . . . . . . . . 93
Transportprocessesintherenaltubule . . 25
Chronickidneydisease . . . . . . . . . . 94
RegulationofbodyfluidpH . . . . . . . 27
Renalreplacementtherapy . . . . . . . . 97
Regulationofcalciumandphosphate . . . 33
Pharmacokineticsinrenaldisease . . . . . 99
Regulationofpotassiumandmagnesium . 35
TheloopofHenle . . . . . . . . . . . . 39 8. Clinicalassessmentoftherenalsystem. .101
Disordersofosmolality . . . . . . . . . . 47 History . . . . . . . . . . . . . . . . .101
Diseasesofthetubulesandinterstitium . . 50 Examination. . . . . . . . . . . . . . .102
Testingthebloodandurine. . . . . . . .107
4. Bodyfluidvolume. . . . . . . . . . . . 55
Imagingandotherinvestigations . . . . .111
Controlofbodyfluidvolume . . . . . . . 55
Renalresponsestosystemicdisorders . . . 60
SingleBestAnswerQuestions(SBAs) . . .119
Diseasesoftherenalbloodvessels . . . . 67
Extended-MatchingQuestions(EMQs) . .125
5. Thelowerurinarytract. . . . . . . . . . 69
SBAAnswers . . . . . . . . . . . . . .129
Organizationofthelowerurinarytract . . 69
EMQAnswers. . . . . . . . . . . . . .133
Congenitalabnormalitiesoftheurinary
Glossary . . . . . . . . . . . . . . . .135
tract . . . . . . . . . . . . . . . . . . 73
Index . . . . . . . . . . . . . . . . . .137
Micturition . . . . . . . . . . . . . . . 74
viii
1
Organization of the kidneys
Objectives
Bytheendofthechapteryoushouldbeableto:
(cid:129) Summarizethemainfunctionsofthekidneysandurinarytract
(cid:129) Statetheanatomicalrelationsoftherightandleftkidneys
(cid:129) Describetheinternalstructureofthekidney
(cid:129) Describethestructureandhistologyofthefiveanatomicalregionsofthenephrons
(cid:129) Namethetwodifferenttypesofnephron,andgivetwowaysinwhichtheydiffer
(cid:129) Outlinethecomplexbloodsupplyofthekidneys
(cid:129) Statehowtheleftandrightrenalveinsdiffer
(cid:129) DescribewheretheJuxtaglomerularapparatusisfound
(cid:129) Listthehormonesproducedbythekidneyandtheirfunctions
(cid:129) Statethethreeembryologicalstagesofkidneydevelopment
(cid:129) Givetwoconditionsresultingfromfailureofmigrationoftheembryologicalkidneys
OVERVIEW OF THE KIDNEY compositionofurineisnotalteredasitistransported
to the bladder. The bladder contents are emptied via
AND URINARY TRACT
theurethra,expulsionfromthebodybeingcontrolled
byanexternalsphincter.Boththeupperandthelower
Thekidneyslieintheretroperitoneumontheposterior urinarytractsareinnervatedbytheautonomicnervous
abdominal wall on either side of the vertebral column system.
(T11–L3).Therightkidneyisdisplacedbytheliver,so Figure1.1showstheanatomyofthekidneysanduri-
itis12mmlowerthantheleftkidney.Theadultkidney narytract.
isapproximately11cmlongand6cmwide,withamass
of140g.Eachkidneyiscomposedoftwomainregions:
Functions of the kidney and the
(cid:129) Anouterdarkbrowncortex urinary tract
(cid:129) Aninnerpalemedullaandrenalpelvis.
1. Excretion: of waste products and drugs – this in-
Therenalpelviscontainsthemajorrenalbloodvessels
volves selective reabsorption and excretion of sub-
and the origins of the ureter. Each kidney consists of
stancesastheypassthroughthenephron
1millionnephrons,whichspanthecortexandmedulla
2. Regulation:ofbodyfluidvolumeandioniccompo-
andareboundtogetherbyconnectivetissuecontaining
sition.Thekidneyshaveamajorroleinhomeostasis
bloodvessels,nervesandlymphatics.
(the maintenance of a constant internal environ-
Thekidneysformtheupperpartoftheurinarytract.
ment) and are also involved in maintaining the
Theurineproducedbythekidneysistransportedtothe
acid–basebalance
bladderbytwoureters.Thelowerurinarytractconsists
3. Endocrine:thekidneysareinvolvedinthesynthe-
ofthebladderandtheurethra.
sis of renin (which generates angiotensin I from
angiotensinogen, and thus has a role in blood
ClinicalNote pressure and sodium balance), erythropoietin
(whichcontrolserythrocyteproduction)andpro-
Approximately1–1.5Lofurineisproducedbythe
staglandins (involved in regulation of renal
kidneyseachday–thevolumeandosmolalityvary
function)
accordingtofluidintakeandfluidloss.
4. Metabolism:VitaminDismetabolizedtoitsactive
form.Thekidneyisamajorsiteforthecatabolismof
low-molecular-weight proteins including several
Theurinarytractepitheliumisimpermeabletowater hormones such as insulin, parathyroid hormone
and solutes unlike the nephrons in the kidney, so the andcalcitonin.
1