Chrissa Mae T.

Catindoy BS Medical Technology 3A

PRELIMS [LECTURE I]: AUBF: Renal Anatomy and Physiology

Renal anatomy

- 2 kidneys are placed on the posterior abdominal wall and located in the sides of vertebral
column – retroperitoneal cavity.
- An adult human kidney has a mass if approximately 150g and measure roughly:
o Length: 12.5 cm
o Width: 6 cm
o Depth: 2.5 cm
- When observed in cross section, two distinct areas of the kidney are apparent:
o Renal cortex
 Approximately 1.4 cm thick and it is glandular in macroscopic
appearance.
 All of the glomeruli are located in the cortex.
o Renal medulla
 Consists of renal tissue shaped into pyramids.
 The apex of these pyramids – papilla.
 Each papilla contains a papillary duct that opens into a cavity – calyx or
calyces – which acts as a funnel to receive urine from the collecting
tubules and pass it into the renal pelvis.
- A funnel-shaped renal pelvis emerges from the indented region of the kidney and
narrows to join with the ureter – a fibro-muscular tube that is approximately 25cm long.
- One ureter extends down from each kidney and connects to the base of the bladder – a
muscular sac that is shaped-like a pyramid.

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- The apex of the “bladder pyramid” is oriented downward and is where the urethra –
originates and extends to the exterior of the body.
o Men: 24cm
o Women: 4cm

Nephron

- Functional units or the tubules of the kidney.

- Each kidney contains approximately 1.3 million nephrons.

Renal circulation

Kidney

- Require a rich blood to execute their function.

- In fact, despite their mass of only 300g or 0.5% of the total body mass, the kidney
receive 25% of the total cardiac output.
- Each kidney is supplied by a single renal artery that originates from the aorta.
- The only organ which an arteriole subdivides into a capillary bed, becomes an
arteriole again, and for the second time, subdivides into a capillary network.

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Glomerulus

- “Renal corpuscle” a tuft or network of capillaries enriched by and intimately related with
the proximal end of renal tubule (Bowman’s capsule).
- Composed of 4 structural: capillary endothelial cells, epithelial cells (podocytes),
mesangium, and basement membrane.
o Podocytes
 The epithelial cells that line the urinary (Bowman’s) space of the
glomerulus.
 These cells completely cover the glomerular capillaries with larger finger-
like processes that interdigitate to form a filtration slit.
 Constitute the glomerular epithelium that forms Bowman’s capsule.

Afferent arteriole

- At the vascular pole supplies blood individually to the glomerulus of each nephron.
- On entering the glomerulus, the afferent arteriole branches into a capillary tuft, which
is related immediately to the epithelial cells of the Bowman’s capsule.
- This branching and anastomosing capillary network comes together to become the
efferent arteriole as it leaves the glomerulus.
- A small branch of an interlobular renal artery that becomes the capillary tuft within
glomerulus.
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Efferent arteriole

- Branches for a second time into a capillary plexus.

- The type of nephron that the efferent arteriole services determines the vascular
arrangement of this capillary plexus.
- The arteriole exiting the glomerulus; formed by re-joining of the anastomosing capillary
network within the glomerulus.

Peritubular capillaries

- That encompasses the outer cortical tubules entirely.

- The network of capillaries (or plexus) that forms the efferent arteriole and surrounds
the tubules of the nephron in the renal cortex.
- Outer cortical nephrons - have short loops of Henle, and the efferent arteriole
branches into a fine capillary plexus – peritubular capillaries.

Juxtamedullary apparatus

- A specialized area located at the vascular pole of nephron.

- Composed of cells from the afferent and efferent arterioles, the macula densa of the
distal tubule, and the extraglomerular mesangium.
- It is an endocrine organ and the primary producer of renin.
o Renin
 A proteolytic enzyme produced and stored by the cells of the
juxtaglomerular apparatus of the renal nephrons.
 Secretion results the formation of angiotensin and secretion of
aldosterone.
 Role: controlling blood pressure and fluid balance.
- The mid and deep juxtamedullary nephrons have long loops of Henle.
- The efferent arterioles of these nephrons first branch into a peritubular capillary –
enmeshes the cortical portions of the tubules, and then divides into a series of long, U-
shaped vessels – vasa recta – which goes down deep into the renal medulla close to
the loops of Henle.

Loops of Henle

- The tubular portion of a nephron immediately following and continuous with the
proximal tubule.
- Located in the renal medulla.
- Composed of thin descending limb, U-shaped segment (hairpin turn), and thin and
thick ascending limbs.
o Thick ascending limb – the straight portion of the distal tubule, ends as the
tubule enters the vascular pole of the glomerulus.

Vasa recta

- Form the beginnings of the venous renal circulation, emerging from deep in the
medulla to form venules and drain into the renal veins.

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- The close relationship of the peritubular capillaries and the renal tubules enables
processing and exchange of solutes between the lumen fluid (ultra-filtrate) and the
bloodstream throughout the nephron.
- The vascular network of long, U-shaped capillaries that forms the peritubular
capillaries and surrounds the loops of Henle in the renal medulla.

(Continuation…)

- The afferent and efferent arterioles exit Bowman’s capsule at the vascular pole in
proximity to each other.
o Vascular pole is also the site of the juxtaglomerular apparatus.
- The morphologically distinct structures that compose the juxtaglomerular apparatus
are:
o Portion of the afferent arteriole – macula densa
o Mesanglial cells
o Specialized portion of the distal convoluted tubule

Macula densa

- Specialized group of cells located at the vascular pole.

Distal convoluted tubule

- The portion of a renal nephron immediately following the loop of Henle.

- The tubule begins at the juxtaglomerular apparatus with the macula densa –
- Distal tubule is convoluted and after 2 or 3 loops becomes the collecting tubule (duct).

Total renal blood flow: 1200ml/min

Total renal plasma flow: 600ml/min

Renal physiology

Urine formation

- Primary excretory function of our kidney.

- Consist of 3 process:
o Glomerular filtration
o Tubular re-absorption
o Tubular secretion
- Through these processes, the kidneys play an important role in:
o Removal of waste products
o Regulation of water and electrolytes
o Maintenance of the body’s acid-base equilibrium
- The kidneys process approximately 180,000ml of filtered plasma each day into a final
urine volume of 600-1800ml.

Glomerulus

- Coil of 8 capillary lobes referred to collectively as the capillary tuft.

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- Located within the Bowman’s capsule and forms the beginning of the renal tubule.
- Function as non-selective filter/sieve of plasma substances with molecular weight of
67,000 daltons.
- 3 structural components of glomerulus:
o Fenestrated endothelial cells of the capillaries
o Basement membrane
o Podocytes or the visceral epithelial cells of Bowmam’s capsule
 Fenestratee endothelial cells
o Make up the first component of the actual filtration barrier.
o It has open pores that is 50-100nm in diameter.
o When viewed from the lumen of the capillary, these opening give the endothelium
a dotted-swiss appearance.
o In addition, the endothelial cells possess a negatively charged coating that
repels anionic molecules.
 Basement membrane
o Separates the epithelium of the urinary space from the endothelium of the
glomerular capillaries.
o 3 layers:
 Lamina rara interna
 Lamina densa
 Lamina rara externa
 Podocytes or Visceral epithelial cells
o Located on the tubular side of the glomerulus, lining Bowman’s space.
o “Foot cell” and relates to their foot-like appearance.
o Completely cover the glomerular capillaries with extending finger-like processes
and interdigitate with neighboring podocytes.
o However, their processes do not touch each other, rather a consistent space of
20-30 nm separates them, forming a snake-like channel that zigzags across the
surface of the glomerular capillaries.

Glomerular filtration barrier

- The structure within the glomerulus that determines the composition of the plasma
ultrafiltrate formed in urinary space by regulating the passage of solutes.
- Consists of capillary endothelium, the basement membrane, and epithelial
podocytes, each coated with a “shield of negativity”.
o Shield of negativity
 A term that describes the impediment produced by negatively charged
components (proteoglycans) of the glomerular filtration barrier.
 Present on both sides of and throughout the filtration barrier, these
negatively charged components effectively limit the filtration of negatively
charged substances from the blood (albumin) into the urinary space.

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**NOTE: As a result of the glomerular mechanisms, every minute approximately 2-3 million
glomeruli filter approximately 120mL of water-containing low-molecular weight substances.

Tubules

- Once the glomerular ultrafiltrate has been formed in the Bowman’s space, hydrostatic
pressure alone moves the ultrafiltrate through the remaining tubular portions of the
nephrons.
- Each tubular portion has distinctively different epithelium, which relates directly to
the unique processes that occur there.
- The tubular portions are:
o Proximal convoluted tubule
o Loop of Henle
o Distal convoluted tubule
o Connecting tubule

Tubular reabsorption

- The movement of substances (by active or passive transport) from the tubular
ultrafiltrate into the peritubular blood or the interstitium by the renal tubular cells.
- Reabsorption mechanism:
o The cellular mechanisms involved in the tubular reabsorption are termed active
transport and passive transport.
 Active transport – the substance must combine with a carrier protein
contained in the membranes of the tubular cells.
 Glucose, amino acids, salts – Proximal convoluted tubule
 Chloride – Ascending loop of Henle
 Sodium – Proximal and distal convoluted tubule
 Passive transport – the movement of molecules across a membrane as a
result of differences in their concentration.
 Urea – Proximal convoluted tubule and ascending loop of Henle
 Sodium – Ascending loop of Henle
 Water – All parts of the nephron except: Ascending loop of Henle

**NOTE: When the plasma concentration of a substance that is normally completely

reabsorbed reaches an abnormally high level, the filtrate concentration exceeds the maximal
re-absorptive capacity of the tubules.

Urine concentration

- Renal concentration begins in the ascending and descending loops of Henle, where the
filtrate is exposed to high osmotic (salt) gradient of the medulla.
- Water is removed by osmosis in the descending loops of Henle.
- Sodium and chloride are reabsorbed in the ascending loops of Henle.
- Final concentration:
o Begins: distal convoluted tubule
o Continues: collecting duct
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- Final concentration is controlled by the following hormones:

Aldosterone Antidiuretic hormone (ADH)

Response to the body’s state of hydration
Response to the body’s need for sodium
Produced: hypothalamus
Produced and released: adrenal cortex
Released: posterior pituitary gland
Promotes sodium reabsorption in the DCT
Makes the walls of the DCT and CD
and potassium excretion
permeable or impermeable to water

Tubular secretion

- Elimination of waste products not filtered by the glomerulus.

- Regulation of acid-base balance in the body.

Renal function test

Glomerular filtration tests

- “Clearance test”
- Standard tests used to measure glomerular filtration rate (GFR)
- Current filterable/clearance substances used are:
o Creatinine
o Cystatin C
o β-2 microglobulin
o Radio isotopes
- Factors to consider:
o Must be neither reabsorbed nor secreted by the tubules
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o Stability of the substance in the urine during a possible 24-hour collection period
o Consistency of the plasma level
o Substance’s availability to the body
o Availability of tests for analysis of the substance
- Example:
o Urea clearance
o Inulin clearance
o Creatinine clearance
- Disadvantages of clearance test using creatinine:
o Bacteria will break down urinary creatinine if specimens are kept at room
temperature for extended periods.
o Not a reliable indicator in patients suffering from muscle-wasting diseases
o Accurate results depend on the accurate completeness of 24 hour collection
o Must be corrected for body surface area
- Creatinine clearance (procedure):
o Involves collection of blood and urine for creatinine testing
o Urine specimen used: 24 hour
o Source of error: improperly timed specimen
o Reported in 120 mL/min

**NOTE: Plasma concentration and clearance are inversely proportional.

- Other examples:
o 125I-iothalamate

 Determines glomerular filtration through the plasma disappearance of

radioactive material.
o β-2-microglobulin
 Dissociates from human leukocyte antigens at a constant rate and is
rapidly removed in the plasma by glomerular filtration.
 More sensitive indicator of a decreased GFR than creatinine clearance.
 Not reliable in patients with a history of immunologic disorders or
malignancy
o Cystatin C
 Produced constantly by all nucleated cells, readily filtered by the
glomerulus and reabsorbed and broken down by the renal tubular cells.
 Recommended for:
 Pediatric patients
 Diabetic patients
 Elderly
 Critically ill patients.
- Calculated Glomerular Filtration Estimates (eGFR)
o Provides estimates of the GFR based on serum creatinine without urine
creatinine.

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Chrissa Mae T. Catindoy BS Medical Technology 3A
o Used for monitoring patients already diagnosed with renal disease or at risk of
renal disease.
 Cockroft and Gault Formula
 Modification of Diet in Renal Disease (MDRD) Formula

Tubular reabsorption test

- “Concentration tests”
- Useful indicators of early renal disease.

Specific gravity Osmolarity

Depends on the number and density of Depends on the number of particles only.
particles. Sodium, chloride, and urea contribute
Urea contributes more than sodium and equally
chloride

**NOTE: Renal concentration in concerned with small particles only.

- Other test:
o Water Deprivation Tests
 Useful for screening only and not used nowadays.
 Fishberg test
 Mosenthal test
 Normal values:
 Deprived of fluid for 16 hours
 Urine specific gravity: 1.025 or above
 overnight water deprivation:
 Urine osmolarity: 800mOsm or above
o Osmometry
 Quantitative measurement of renal concentrating ability.
 Reported in milliosmole (mOsm)
 Determined by colligative property and comparing with the value
obtained from the pure solvent (water).
 Colligative properties:
 Boiling point
 Osmotic pressure
 Freezing point
 Vapor pressure
- In the clinical laboratory, depression in freezing point and vapor pressure are used.
o Freezing point osmometers
 1st principle incorporated into clinical osmometers.
 1 mol (1000mOsm) will lower the freezing point by 1.86°C.

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o Vapor pressure osmometers
 Uses microsamples <0.1mL.
 Measures dew point (vapor)
 Depression of dew point temperature is proportional to the decrease in
vapor pressure.
- Clinical significance:
o Initial evaluation of renal concentrating ability
o Monitoring the course of renal disease
o Monitoring fluid and electrolyte therapy
o Establishing differential diagnosis of hypernatremia and hyponatremia
o Evaluating secretion and renal response to ADH

Tubular secretion and renal blood flow tests

o PAH Test
o PSP tests
o Urinary ammonia and Titratable acidity
 Determines the defective function in the ability of the kidney to produce
an acidic urine.
 Fresh or Toluene-preserved urine specimens collected at 2-hour
intervals from patients who have been primed with an acid load consisting
of oral ammonium chloride are tested for the amount of free H+ and total
acidity of the specimen.
- Urine Acidity:
o A normal person excretes 70mEq/day of acid.
o Alkaline tides appearing shortly after arising and post-prandial at 2pm and
8pm.
- Clinical Significance
o Renal Tubular Acidosis
 Inability to produce an acid urine in the presence of metabolic acidosis.
 It is associated with an constantly alkaline urine
 May be due to defects associated with:
 Proximal convoluted tubule
 Distal convoluted tubule

Urine composition

- Water: 91-96%
o Organic Components:
 Urea (60% to 90%)  Pigments
 Creatinine  Fatty acids
 Uric acid  Mucin
 Hippuric acid  Enzymes
 CHO  Hormones

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o Inorganic Components:
 Chloride  Phosphate
 NaCl  Ammonium
 Potassium  Magnesium
 Sulfate  Calcium

Specimen collection

Gloves

- Should be worn at all times.

Specimen container

- Clean, dry, leak-proof containers up of clear material (to allow determination of color
and clarity) and with a wide mouth and a wide, flat bottom to prevent overturning.
- Disposable containers are recommended.
- Recommended capacity is 50 ml.

**NOTE: All specimens must be labeled properly.

**NOTE: Requisition form must be accompanying specimens.

Specimen rejection

 Improperly labeled and collected specimens should be rejected by the laboratory and
request for a new specimen.
 Specimens in unlabeled containers.
 Non-matching labels and requisition form.
 Specimens contaminated with feces or toilet paper.
 Containers with contaminated exteriors.
 Specimens of insufficient quantity.

Specimen integrity

- After collection, specimens must be sent to the laboratory and tested within 2 hours.
- Preserve the specimen by refrigeration or use of an appropriate chemical preservative.
o Increased analytes:
 pH  Odor
 Bacteria  Nitrite
o Decreased analytes:
 Clarity  Urobilinogen
 Glucose  RBCs and WBCs
 Ketones  Trichomonas
 Bilirubin
o Modified/darkened:
 Color

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Specimen preservation

Physical preservation

 Refrigeration
o Most routinely used method.
o Temperature: 2-8°C
o Effects:
 Decreases bacterial growth and metabolism.
 Increases specific gravity when measured by urinometer.
 Precipitation of amorphous phosphates and urates.
o Specimen must return to room temperature before chemical testing by reagent
strips (this will correct specific gravity and may dissolve some of the amorphous
urates; also enzymes reactions on the strips perform best at room temperature)

Chemical preservation

- The routine use of preservation is not recommended; may be used when refrigeration is
impossible.
- Ideal preservative:
o Bacterial
o Can inhibit urease
o Can preserve formed elements
o Should not interfere with chemical test

Types of specimen preservation:

Refrigeration

 Advantages:
o Does not interfere with chemical test.
 Disadvantages:
o Precipitate amorphous phosphates and urates.
o Raises specific gravity by urinometer.
 Additional information:
o Prevents bacterial growth for 24 hours.

Thymol

 Advantages:
o Preserves glucose and sediments well.
o Does not interfere with reagent strip tests for protein.
 Disadvantages:
o Interferes with acid precipitation tests for protein.
 Additional information:
o Preservative for crystals in urine.

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Formalin

 Advantages:
o Excellent sediment preservative.
 Disadvantages:
o Interferes with glucose, blood, LE, and copper reduction.
o If used in too large concentrations, it will precipitate protein.
 Additional information:
o Rinse specimen container with formalin to preserve cells and casts.
o Preservative for Addis count.
o Preservative for crystals in urine.

Boric acid

 Advantages:
o Prevents bacterial growth and metabolism.
 Disadvantages:
o When used in large amounts, it may precipitate crystals.
o Interferes with drug and hormone analyses.
 Additional information:
o Keep pH at about 6.0.
o Bacteriostatic at 18g/L; can be used for culture transport.
o Preservative for crystals in urine.

Toluene

 Advantages:
o Does not interfere with routine tests.
 Disadvantages:
o Floats on surface of specimens and clings to pipettes and testing materials.
o Not effective against bacteria already present in the urine.

Saccommano fixative

 Advantages:
o Preserves cellular elements.
 Additional information:
o Used for cytology studies.

Specimen test

Random specimen

- Most commonly received specimen.

- Collected at any time.
- Used for routine screening test.
- Affected by dietary intake or physical activity just before collection.

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First morning (8-hour) specimen

- Collected immediately on arising and delivered to the lab within 2-hours.

- Ideal screening specimen.
- Concentrated and acidic.
- For preventing false-negative pregnancy test result.
- For nitrite testing.

2-hours post prandial

- Collected shortly before consuming a routine meal and collecting again 2 hours after
eating.
- For monitoring insulin therapy in diabetic patients.

24-hour (timed) specimen

- For analytes that exhibit diurnal variations, (catecholamine, 17-hydroxysteroids,

electrolytes) and are affected by changes brought about by daily activities such as
exercise, meals, and body metabolism.
- Patients must be instructed on the procedure for collecting a timed specimen.
o Must begin and end the collection period with an empty bladder.
o Addition of urine formed before the start of collection period – falsely elevated.
o Failure to include urine produced at the end of collection period – falsely
decreased.
- All specimens should be refrigerated or kept in ice during the collection period and may
also require of a chemical preservative.

Early afternoon specimen

- For urobilinogen determination.

- Because urobilinogen excretion is enhanced in alkaline urine, the specimen of choice
for quantifying or monitoring is a 2-hour collection following the midday meal.

12-hour urine

- For Addis count.

 Addis count
o First procedure to standardize the quantitation of formed elements in the urine.
o Quantities formed elements in a 12-hour overnight urine collection using
heamocytometer.
o Normal values:
 RBCs  Epithelial cells
 WBCs  Hyaline casts

**NOTE: If any of these cell changes was noted, it indicates a disease process.

Catheterized urine

- For bacterial culture.

- If a routine urinalysis is also requested.
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- Collected under sterile conditions by passing a catheter through the urethra into the
bladder.
- May also be used to measure function of individual kidney.

Midstream clean-catch specimen

- An alternative to the catheterized specimen.

- Safer, less traumatic method (bacterial culture and routine urinalysis), and less
contamination (epithelial cells and bacteria).

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