DEPARTEMEN PENYAKIT DALAM FK UNSRI/RSMH Struktur Ginjal : 2 ginjal - filter darah, produksi urine 2 ureter - transpor urine (ginjal ke bladder) bladder - reservoir of urine uretra - transpor urine letak retroperitoneal, pd dinding posterior abdominal
Terletak dari T12-L3 vertebral columna, disamping m. psoas major
Bagian superior dilindungi iga 11, 12
Ginjal kanan lebih rendah dari kiri (karena terdapat lobus kanan hepar)
Ukuran 12 x 5 x 2,5 cm Berat 150 gram
Seperti kacang, warna merah coklat
kidney levels berubah sewaktu respirasi dan perubahan postural 1. renal fascia (outer) flexible, pergerakan ginjal saat respirasi Ditutupi oleh lapisan lemak
Martini p 953 Luar; korteks, dalam: medulla 6-18 conical renal pyramids apex - renal papilla projects into the renal sinus renal columns extend from cortex inward to renal sinus between adjacent renal pyramids
granular texture similar to that of the cortex ureter masuk ke sinus renalismeluas ruang- renal pelvis pelvis bercabang 2-3 major calyces 6-8 minor calyces Tiap minor calyx terdapat papilla pyramid renalis Duktus di papilla menghubungkan dinding calyx dan hasil urine dari korteks Urine melalui calyces menuju ureter Berasal dari aorta abdominalis, arteri renalis masuk ke hilus ginjal dan bercabang:
1. Arteri interlobaris- melewati renal columns and reach junction between medulla and cortex
2. Arteri arkuata melengkung, berjalan di antara piramid
3. Interlobular arteriole tersusun paralel dalam korteks dan membentuk arteriole aferen
Vena renalis keluar dari hilus dan masuk ke Vena cava inferior = unit fungsinal ginjal 1 juta/ginjal Tubular components: 1. Glomerular (Bowmans) capsule double-walled cup simple squamous epithelium 2. Proximal convoluted tubule - coiled 1 st section simple cuboidal epithelium with microvilli 3. Loop of Henle - hair-pin loop thin descending limb, thick ascending limb 4. Distal convoluted tubule - last section simple cuboidal epithelium specialised region - Juxta glomerular apparatus
Distal convoluted tubule opens into the collecting system collecting ducts papillary ducts minor calyx
Made up of blood vessels:
1. Glomerulus - network of capillaries within Bowmans capsule
2. Afferent arteriole - leading into glomerulus
3. Efferent arteriole - leading out of glomerulus
4. Peritubular capillaries - surrounding tubules
5. Vasa recta - specialised loops of blood vessels around long Loop of Henle (juxtamedullary nephrons)
Transpor urine dari ginjal ke vesica urinaria
Panjang20-30 cm
Dinding ototperistaltik, mendorong urine ke v.u
retroperitoneal
pressure in the bladder compresses ureter, helps prevent backflow of urine
(physiological valve) - still allows urine to flow into the bladder Organ kantung berotot retroperitoneal, posterior pubic symphysis Kapasitas ~ 300-400 ml (max = 1000 ml) Saat kosong: seperti balon kempis, rugae Laki-laki: anterior rektum, di atas prostat Perempuan: inferior uterus. Anterior vagina
superior surfaces - peritoneum
middle umbilical ligament - superior border to umbilicus
lateral umbilical ligaments - sides of bladder to umbilicus
At base, tough ligamentous bands anchor bladder to pelvic and pubic bones
Trigone : triangular area bounded by openings of ureters and exit to urethra
cystitis - inflammation of the bladder wall Female ~ 4cm long opens to exterior between clitoris and vaginal opening
Male ~ 20 cm long passes through prostate gland
pierces urogenital diaphragm
enters penis and extends throughout length opens at urethral orifice Reseptor terstimulasi bila: terisi ~ 200 ml Serabut aferen ke s.c. motor neurons di dinding vesica urinaria Kontraksi m. detrusor dan meningkatkan tekanan Relaksasi internal and external sphincter - external Jika external sphincter tidak relaksasi, internal sphincter tertutup dan dinding vu relaksasi Jika volume >500 ml, refleks mictie cukup untuk kontraksi sphincter interna dan relaksasi sphincter externa Fungsi Ginjal :
1. Mengeluarkan kotoran dari tubuh (urine) 2. Mengatur keseimbangan cairan, maintenance homeostasis FUNGSI EKSKRESI Mempertahankan osmolalitas plasma sekitar 285 mOsmol Mempertahankan volume dan tekanan darah dengan mengatur ekskresi Na Mempertahankan konsentrasi plasma elektrolit Mempertahankan pH plasma sekitar 7,4 Mengekskresikan produk akhir nitrogen dari metabolisme protein (urea, asam urat dan kreatinin) Ekskresi ebagian besar obat FUNGSI NONEKSKRESI Sintesis dan aktivasi hormon: Renin, eritropoetin, vitamin D, prostaglandin, degradasi hormon polipeptida, insulun, glukagon, parathormon, prolaktin, hormon pertumbuhan, ADH dan hormon gastrointestinal Menyaring 200 L darah /hari, memungkinkan toksin- toksin, sampah metabolik dan ion excess keluar dari tubuh lewat urin
Meregulasi volume dan zat-zat kimia yang terbentuk oleh darah
Mengatur keseimbangan antara air dan garam, juga asam dan basa Gluconeogenesis selama puasa
Menghasilkan renin untuk membantu regulasi tekanan darah dan eritropoetin untuk merangasang produksi sel- sel darah merah
Aktivasi vitamin D Renal corpuscle Terdiri atas glomerulus dan kapsul Bowman
Endotel Glomerular fenestrated epithelium that allows solute-rich, virtually protein-free filtrate to pass from the blood into the glomerular capsule Figure 25.4b Bagian distal portion dari distal tubulus convoluted yang dekat ke collecting ducts Terdapat dua jenis sel penting, yaitu: Intercalated cells Sel-sel Kuboid dengan microvilli Berfungsi pada maintain keseimbangan asam basa tubuh Principal cells Sel-sel kuboid tanpa microvilli Membantu maintain cairan tubuh dan keseimbangan garam Cortical nephrons 85% of nephrons; lokasi pada cortex
Juxtamedullary nephrons: Berlokasi di cortex-medulla junction Mempunyai loops of Henle yang menginvasi ke dalam medulla Mempunyai segmen yang ketebalan lebih extensive Berperan dalam produksi konsentrasi urin Figure 25.5b Every nephron has two capillary beds
Glomerulus Peritubular capillaries
Each glomerulus is:
Fed by an afferent arteriole Drained by an efferent arteriole Blood pressure in the glomerulus is high because:
Arterioles are high-resistance vessels Afferent arterioles have larger diameters than efferent arterioles
Fluids and solutes are forced out of the blood throughout the entire length of the glomerulus Figure 25.5a Afferent and efferent arterioles offer high resistance to blood flow
Blood pressure declines from 95mm Hg in renal arteries to 8 mm Hg in renal veins Resistance in afferent arterioles: Protects glomeruli from fluctuations in systemic blood pressure Resistance in efferent arterioles: Reinforces high glomerular pressure Reduces hydrostatic pressure in peritubular capillaries Where the distal tubule lies against the afferent (sometimes efferent) arteriole
Arteriole walls have juxtaglomerular (JG) cells Enlarged, smooth muscle cells Have secretory granules containing renin Act as mechanoreceptors Macula densa Tall, closely packed distal tubule cells Lie adjacent to JG cells Function as chemoreceptors or osmoreceptors Mesanglial cells: Have phagocytic and contractile properties Influence capillary filtration Figure 25.6 Filter that lies between the blood and the interior of the glomerular capsule
It is composed of three layers Fenestrated endothelium of the glomerular capillaries Visceral membrane of the glomerular capsule (podocytes) Basement membrane composed of fused basal laminae of the other layers Figure 25.7a Figure 25.7c The kidneys filter the bodys entire plasma volume 60 times each day
The filtrate: Contains all plasma components except protein Loses water, nutrients, and essential ions to become urine
The urine contains metabolic wastes and unneeded substances Urine formation and adjustment of blood composition involves three major processes Glomerular filtration Tubular reabsorption Secretion Figure 25.8 Principles of fluid dynamics that account for tissue fluid in all capillary beds apply to the glomerulus as well The glomerulus is more efficient than other capillary beds because: Its filtration membrane is significantly more permeable Glomerular blood pressure is higher It has a higher net filtration pressure Plasma proteins are not filtered and are used to maintain oncotic pressure of the blood The pressure responsible for filtrate formation
NFP equals the glomerular hydrostatic pressure (HP g ) minus the oncotic pressure of glomerular blood (OP g ) combined with the capsular hydrostatic pressure (HP c ) NFP = HP g (OP g + HP c ) The total amount of filtrate formed per minute by the kidneys
Factors governing filtration rate at the capillary bed are: Total surface area available for filtration Filtration membrane permeability Net filtration pressure GFR is directly proportional to the NFP
Changes in GFR normally result from changes in glomerular blood pressure Figure 25.9 If the GFR is too high:
Needed substances cannot be reabsorbed quickly enough and are lost in the urine
If the GFR is too low: Everything is reabsorbed, including wastes that are normally disposed of Three mechanisms control the GFR
Renal autoregulation (intrinsic system) Neural controls Hormonal mechanism (the renin-angiotensin system) Under normal conditions, renal autoregulation maintains a nearly constant glomerular filtration rate
Autoregulation entails two types of control Myogenic responds to changes in pressure in the renal blood vessels Flow-dependent tubuloglomerular feedback senses changes in the juxtaglomerular apparatus When the sympathetic nervous system is at rest: Renal blood vessels are maximally dilated Autoregulation mechanisms prevail Under stress: Norepinephrine is released by the sympathetic nervous system Epinephrine is released by the adrenal medulla Afferent arterioles constrict and filtration is inhibited The sympathetic nervous system also stimulates the renin-angiotensin mechanism Is triggered when the JG cells release renin Renin acts on angiotensinogen to release angiotensin I Angiotensin I is converted to angiotensin II Angiotensin II: Causes mean arterial pressure to rise Stimulates the adrenal cortex to release aldosterone As a result, both systemic and glomerular hydrostatic pressure rise Renin release is triggered by: Reduced stretch of the granular JG cells Stimulation of the JG cells by activated macula densa cells Direct stimulation of the JG cells via 1 -adrenergic receptors by renal nerves Angiotensin II Figure 25.10 LFG/GFR adalah mengukur berapa banyak filtrat yang dihasilkan oleh glomerulus Merupakan pengukuran paling baik untuk menilai fungsi eksresi Filtrasi dipengaruhi oleh aliran plasma , perbedaan tekanan, luas permukaan kapiler, dan permeabilitas kapiler LFG merupakan jumlah dari hasil semua nefron (rata- rata 1 juta tiap ginjal)
Rumus Homer Smith untuk mengukur renal klirens :
C = U X V P C = Klirens U = Konsentrasi zat marker dalam urin V = Volume urin P = Konsentrasi zat marker dalam plasma