Renal & Urologic System
The renal and urologic system
- the kidney and ureters are part of the upper urinary tract
- the bladder and urethra are part of the lower urinary tract
The kidneys serve as both endocrine organs and target of endocrine action
- control mineral and water balance
- The function of the kidneys: it's to filter waste products and remove excess fluid from the blood
o Filtering units are called nephrons
§ Glomerulus
· Filters the blood and the tubule it's going to return needed substances back to your blood as well as secrete waste
Function of the renal system
- Kidneys help to maintain homeostasis
o Water and electrolyte balance
- Kidneys respond to increase in water content by increasing the output of water in urine; restoring body water to normal levels
- Kidneys participate in the production of vascular active substances via the renin angiotensin aldosterone system
o Influences peripheral vascular resistance
- Excretion of waste And foreign substances
o The Kidneys and liver work in partnership
§ The liver will metabolize many organic molecules into water soluble form that can be more easily handled by the kidney
- Regulates red blood cell production
- Regulation of acid base balance
o Enters the body via ingestion
o The body has to excrete acids and bases to maintain balance
o Regulates the concentration of free hydrogen ions
o Elimination and synthesis
- Regulation of vitamin D production and regulation of calcium and phosphate balance
o When calcium drops the parathyroid gland releases parathyroid hormones; That stimulate the kidneys, bones, and the GI tract to provide more calcium
- Gluconeogenesis
o When the intake of carbohydrates is stopped, the body begins to synthesize new glucose from non carbohydrate sources; occurs in the liver
o The body is equipped to handle short term imbalances between input and output; The kidneys will match input with output
Blood flow
- The kidney is a ball of vasculature; Does so much work, it needs a lot of oxygen
- Cardiac muscle: 9.7mL/100g/min (Muscle needs a lot of oxygen)
- Kidneys 6.0mL/100g/min
- Liver 2.0mL/100g/min
Nephron
- Approximately 180 liters of blood goes into the kidney, 99% of the fluid that goes into the kidney gets reabsorbed; we excrete about 1.8 liters per day which is 1%
- Blood enters the nephron through afferent arterials
- It goes to a cluster of tiny blood vessels
- Glomerulus allows smaller molecule waste and fluids (Water) to pass into the tubules; larger molecules such as proteins and blood cells Stay inside with the blood vessel
- Peritubular capillaries
o As the filtered fluid moves along inside the tubule the capillaries are going to reabsorb almost all the water along with minerals and nutrients the body needs
o The tubule helps remove excess waste from the blood
o Remaining fluid waste in tubule becomes urine
- 65% of the reabsorption happens in the proximal tubule
o Ions Reabsorbed: sodium potassium chloride calcium, magnesium, & bicarbonate
o Water
o Amino acid, urea, and 100% of glucose
o Ex: Diabetes
§ Excessive glucose makes it past the proximal tubule
§ High of High concentration of glucose brings water into the tubule; resulting in peeing out much more urine than normal (symptom of diabetes)
- Loop of henley
o The descending loop; reabsorption of water
o Ascending loop: reabsorb ions, bicarbonate, water
- Distal tubule
o Absorbing more ions, bicarbonate, water
- Collecting duck
o Reabsorb sodium, chloride, bicarbonate, water, and urea
- Peritubular capillary surrounds the tubule
o designed to help with reabsorption of materials from the tubule as well as secretion
o Substances are eliminated as waste: including urea, uric acid, creatinine, hydrogen ions, certain drugs and ammonia
Renin Angiostatin Aldosterone System
- Important role in blood pressure
- Decrease in blood pressure
o Granular cells sense a decrease in blood pressure;
o Distal convoluted tubule respond to the decrease in sodium concentration
§ Blood pressure fluid moves slower through the nephrons; more time for sodium to get reabsorbed back into the body
§ Distial convoluted tubules notice this decreased concentration and tells the granular cells to release renin
o Sympathetic nervous system may kick in with the drop in blood pressure also signals the release of renin
- Releases renin (enzyme) from kidney In peripheral circulation
- Liver produces angiotensinogen
- Renin transforms angiotensin into Angiotensin 1
- The lungs produce an enzyme called Angiotensin converting enzyme (ACE)
o ACE converts angiotensin 1 into Angiotensin 2
§ Angiotensin 2 is a Vasoconstrictor; helps increase blood pressure in addition to angiotensin 2;
- Angiotensin 2 circulates to adrenal cortex to stimulate aldosterone
o Aldosterone signals the distal convoluted tubules to pull sodium back into circulation
o Water follows sodium back into blood circulation
- Blood volume increases in blood pressure
- Angiotensin 2 makes it to the hypothalamus
o hypothalamus sends signal to the posterior pituitary gland to release antidiuretic hormone ADH
o ADH is released; signaling distal, convoluted, tubule‘s, and collecting duct to pull water back into circulation in the body; increasing blood volume that will help increase blood pressure
Renal Calculi (Kidney Stones)
- Solid piece of material that forms in the kidney from substances in the urine
- Small as a grain of sand can also be very large as a Pearl
- Most kidney stones pass through the body without any resistance from medicine
- It can go away or it could get stuck in the urinary tract that will block urine flow
- Kidney stones are likely to occur in people between the ages of 20 and 50
- White people are more susceptible to kidney stones than black
- Men also develop more kidney stones than women
- Other risk factors
o Dehydration
o Obesity/ poor diet with high levels of protein salt or glucose
o Hyperparathyroid condition, inflammatory bowel disease
o Medication such as diuretics, anti-seizure drugs and calcium based antacids
Chronic Kidney Disease and Failure
- Impairment of glomerular filtration is going to result in renal insufficiency or failure
- Risk factors
o Diabetes hypertension, cardiovascular disease, obesity
o Less common etiologies:
§ Glomerularnephritis (inflammation/damage to filtering part of Kidneys), lupus, poly cystic kidney disease
§ Chronic kidney disease can develop as a complication of overuse Of NSAIDs
· NSAIDs decrease prostaglandins in the body
o Too much of A decrease will cause afferent arterials to constrict; decreased amount of blood to the nephron decreased oxygenation of nephrons
o Decreased oxygen to the kidney causes damage
§ Cocaine
§ Development and progression of cardiovascular disease (Morbidity/Mortality)
§ Anemia, bone disease, acute kidney injury
§ Drug overdose
o Reversible with proper treatment
§ Dialysis until kidney recovers
o Irreversible
§ Chronic disease that affects the kidneys such as diabetes or hypertension; congestive heart failure
- Cardiovascular and pulmonary complications of chronic kidney disease
o Hypertension, atherosclerosis, anemia, bleeding disorder, Renal osteodystrophy (bone changes), proximal myopathy (weakness of skeletal muscle), Peripheral neuropathy, ulcers and immunosuppressants (leads to lots of infections)
§ These complications are reversible with dialysis patients
o Patients on dialysis can also develop other problems
§ Heart failure is prevalent in chronic kidney disease
· Occurs in about 40% of those over 65 and
· 65 to 70% of patients with end stage renal disease have congestive heart failure
o Acute or chronic renal failure is also associated with pulmonary complications
o Pulmonary edema is the most serious; fluid overload
o Fibrinous Pleuritis:
§ Found in 40% of patients who die of chronic renal failure
§ Pleuratic Chest pain
o Pulmonary complications
§ Pulmonary calcification, pleural effusion, respiratory tract infections
o Treatment of end stage renal disease It's also associated with pulmonary complications
§ Patients are treated with hemodialysis
· Show a decrease in arterial oxygen concentration during treatment
o Peritoneal dialysis is commonly associated with pleural effusion as well as elevated diaphragm which makes breathing difficult
- Treatment of chronic renal failure
o Slow the progressive deterioration in kidney function, minimize the complications associated with it
o Medication are used to control blood pressure, heart failure, and to improve any abnormalities in lipids
§ It inhibits the inflammatory process involved in plaque formation
o Renal replacement therapy
§ Hemodialysis or peritoneal dialysis
· Dialysis is a process that replaces the kidneys excretory function through a semi permeable membrane in a rinsing solution to filter out toxic waste substances from the blood
· Dialysis allows for the control of fluid and electrolyte balance
· Hemodialysis patients go to a clinic, treatments are about 3 to 4 hours
· Peritoneal dialysis: Dialysis fluid is introduced into the peritoneal cavity via a permanent catheter placed in the abdominal wall
o waste product and extra fluids are filtered out from the vascular system through the peritoneal membrane into the solution
o Kidney transplant
§ Best treatment for end stage renal disease in a young patient
§ this will offer the best opportunity for normal renal function as well as an improved lifestyle
- Exercise and chronic kidney disease failure
o Patients with chronic kidney disease have impaired exercise tolerance and reduced muscle strength/endurance; Becomes more pronounced as the kidney disease progresses.
§ Contributing factors include anemia, cardiovascular disease, chronic physical inactivity, skeletal muscle dysfunction, and metabolic acidosis.
o Exercise capacity is going to be reduced to approximately 50 to 60% of normal
o Skeletal muscle fatigue
§ patients with chronic kidney disease have notable skeletal muscle atrophy and weakness
o Many dialysis patients suffer from neuropathy - Major disability
o Reduced flexibility and impaired coordination
o Resistance training is recommended.
- clinical implications for physical therapy
o Resistance training has been reported to improve muscle strength and muscle mass as well as functional performance, Peak exercise capacity.
o Exercise is going to help reduce inflammation, maintain body weight, increase protein utilization, nitrogen retention.
o in dialysis patients, resistance exercise produces additional benefits; enhances cardio Vagaro tone at rest, Leading to lower resting heart rate and reduction in the incidence of cardiac arrhythmias.
o Improved quality of life
o As a PT we should look at lab values (Hgb, Hct, glucose, potassium, calcium, creatinine), specifically if they're going through dialysis.
§ Appropriate treatment modifications need to be made if the lab values are abnormal.
o in patients with chronic kidney disease Max exercise capacity and muscle strength decreases as renal disease progresses; long before end stage renal disease develops.
§ Aerobic and resistance exercise is going to be extremely beneficial so that we can help prevent physical deterioration as the disease progresses.
o 4 parameters: mode, intensity, duration, and frequency
o 5th Parameter: the timing of exercise relative to patients in dialysis treatment
§ patients who perform exercise during dialysis benefit from improved dialysis efficiency by 10 to 15% with greater removal of waste product
Glomerular Disease
- Nephritis and nephrotic syndrome
- Kidneys are designed to filter toxins out of your bloodstream and excrete them in the urine.
o Red blood cells and proteins may be excreted in the urine in people who have glomerular disease.
o Toxins may be retained in the body; this disease can occur by itself or maybe Associated with an underlying medical condition that affects other organ systems such as lupus or diabetes.
- Signs and symptoms may include elevated blood pressure, fluid retention, fatigue, decrease in urine
- Key feature of Glomerular Nephritis
o Blood in the urine (hematuria)
o May not have any symptoms; condition may go unnoticed until they have a routine urine analysis where they will find blood in the urine.
§ Impaired kidney function as a result
o Causes could be lupus or certain bacterial or viral infections.
§ Unreasonable immune response where your body actually attacks your kidneys.
- Key features of glomerular nephrotic
o Protein in the urine known as protein urea.
o No blood in the urine,
o Kidney function may worsen as nephrotic syndrome progresses.
o Caused by diabetes.
o Treatment depends on what type, underlying cause, severity of signs and symptoms.
o If it is caused by an infection that will improve once the infection is treated
o other types may require treatment with medications that actually suppress the immune system
§ If your immune system is attacking your kidney, suppression of the immune system will help
Disorders of the bladder and urethra
- Bladder cancer
o Cause is not known but there are multiple risk factors:
§ Smoking, occupational exposure to hazardous chemicals
o More than 90% of cases occurs in people older than 55 years.
o Risk factor:
§ Age
§ Whites are twice as likely as African Americans to develop the disease.
§ Men developed bladder cancer four times more often than women.
o Blood in urine is the most common sign of bladder cancer
Urinary inconsistency
- The ability to hold urine and pass urine is a very complex process; it involves the coordination of muscle, nerves, signals, hormones.
o Regulated by the brain and spinal cord.
- Define as a complaint of involuntary urine loss.
o Stress urinary incontinence
§ Involuntary loss of urine on effort or physical exertion; sneezing or coughing; occurs during activities that increase intra-abdominal pressure.
o Urgency urinary incontinence
§ patients complain of involuntary loss of urine associated with urgency
· Sudden compelling desire to urinate.
· Detrusor instability: A condition in which the bladder contracts at small volumes
o Often in response to triggers such as running water or arriving home after being out.
- Bladder diary may be necessary to determine the frequency, timing, and the amount.
- To manage your urinary incontinence will depend on the type of incontinence, age, general health.
- Conservative, pharmacological, Surgical (categories)
o Physical therapists have an important role in the assessment and treatment of urinary incontinence.
o PT can guide rehabilitation of the muscle imbalance and pelvic alignment.
o Promote pelvic muscle awareness and function through biofeedback, therapeutic exercise, neuromuscular, reeducation, and behavioral management.
o Pelvic rehab program - designed to prevent the impairments of reoccurrence and restore bowel, bladder, sexual, and supportive muscle functioning.
Neurogenic Bladder Disorder
- Can lead to a significant decrease of quality of life.
- Neurological conditions: Parkinson's disease multiple sclerosis, spinal cord injury, diabetes, and dementia
- Treatments:
o Catheters, Botox injections, Bladder training, surgery
- PT’s treating patients with neurological conditions need to be aware of bladder and bowel functions.
o Functional mobility
§ They can get on and off the toilet; learn how to sit in relaxed position on the toilet; ability to relax the abductor muscles.
- PT’s should be familiar with complications with neurogenic blaster disorders; including Potential for urinary tract infections and renal damage
o Through a program of exercise and behavioral intervention, a pelvic health physical therapist could help improve and even eliminated this issue.
InterstitIal Cystitis (ICC)/Painful Bladder Syndrome (BPS)
- Long term bladder pain
o feeling of discomfort and pressure in the bladder area
o Last for six weeks or more with no infection or other clear cause
o lower urinary tract symptoms
o regular urgent need to pass urine
irritable bowel syndrome or fibromyalgia