VISHNU DENTAL COLLEGE

DEPARTMENT OF PERIODONTICS AND

IMPLANTOLOGY

SEMINAR ON
STRUCTURE AND FUNCTION OF LIVER AND KIDNEY

2014-2017

GUIDED BY: H.D.MANASA

PRESENTED BY: R.UDAY BHASKAR

CONTENTS :
KIDNEY
Introduction
Anatomy
Blood and nerve supply
Nephron
Functions
Formation of urine
Excretion of metabolic waste products and foreign chemicals
Regulation of water and electrolyte balances
Regulation of arterial pressure
Regulation of acid base balanc
Glucose synthesis
LIVER
Introduction
Anatomy
Blood and nerve supply
Functions
The Liver Stores Iron as Ferritin
Coagulation
Excretion of drugs and other hormones
Measurement of Bilirubin
Jaundice
Drugs
Clinical significance
conclusion

KIDNEY ANATOMY
The kidneys are bean shaped organs that serve several essential regulatory roles in
vertebrate animals
Two kidneys lie on the posterior wall of the abdomen, outside the peritoneal cavity.
Weighs 150 gm
Medial side of each kidney contains an indented region called the hilum
The kidney is surrounded by a tough, fibrous capsule
Outer cortex and inner medulla.
Medulla is divided into multiple cone-shaped
masses of tissue called renal pyramids.
The base of each pyramid originates at the border between the cortex and medulla
and terminates in the papilla..
The outer border of the pelvis is divided into open-ended pouches called major
calyces that extend downward and divide into minor calyces, which collect urine from
the tubules of each papilla
NEPHRON:
Functional Unit of the Kidney
Each kidney -1 million nephrons, each capable of forming urine.
The kidney cannot regenerate new nephrons.
Therefore, with renal injury, disease, or normal aging, there is a gradual decrease in
nephron number.
2 parts : a renal corpuscle and renal tubule
Renal corpuscle has two components - glomerulus and glomerular capsule
(Bowans capsule)
Fluid filtered from the glomerular capillaries flows into Bowmans capsule and then
into the proximal tubule, which lies in the cortex of the kidney.
From the proximal tubule, fluid flows into the loop of Henle, which dips into the renal
medulla. Each loop consists of a descending and an ascending limb. The walls of the
descending limb and the lower end of the ascending limb are very thin and therefore
are called the thin segment of the loop of Henle.

 After the ascending limb of the loop has returned partway back to the cortex, its
wall becomes much thicker, and it is referred to as the thick segment of the
ascending limb.
At the end of the thick ascending limb is a short segment, which is actually a plaque
in its wall, known as the macula densa.
Beyond the macula densa, fluid enters the distal tubule, that lies in the renal cortex.
This is followed by the connecting tubule and the cortical collecting tubule, which
lead to the cortical collecting duct.
The initial parts of 8 to 10 cortical collecting ducts join to form a single larger
collecting duct that runs downward into the medulla and becomes the medullary
collecting duct.
The collecting ducts merge to form progressively larger ducts that eventually empty
into the renal pelvis through the tips of the renal papillae. In each kidney, there are
about 250 of the very large collecting ducts, each of which collects urine from about
4000 nephrons.
FUNCTIONS:
Excretion of metabolic waste products and foreign chemicals
Regulation of water and electrolyte balances
Regulation of body fluid osmolality and electrolyte concentrations
Regulation of arterial pressure
Regulation of acid-base balance
Secretion, metabolism, and excretion of hormones
Gluconeogenesis
URINE FORMATION:
3 basic processes
1. glomerular filtration
2. tubular reabsorption
3. tubular secretion

GLOMERULAR FILTRATION:
Urine formation begins with filtration of large amounts of fluid through the
glomerular capillaries into Bowmans capsule.
Like most capillaries, the glomerular capillaries are relatively impermeable to
proteins, so that the filtered fluid (called the glomerular filtrate) is essentially proteinfree and devoid of cellular elements, including red blood cells.
The concentrations of other constituents of the glomerular filtrate, including most
salts and organic molecules, are similar to the concentrations in the plasma.
In the average adult human, the GFR is about 125 ml/min, or 180 L/day.
About 20% of the plasma flowing through the kidney is filtered through the
glomerular capillaries.
The filtration fraction is calculated as follows:
Filtration fraction = GFR/Renal plasma flow
Even with this high rate of filtration, it is the glomerular capillary membrane that
normally prevents filtration of plasma proteins.
The glomerular capillary membrane is similar to that of other capillaries, except that
it has three (instead of the usual two) major layers:
(1) the endothelium of the capillary,
(2) a basement membrane,
(3) a layer of epithelial cells (podocytes) surrounding the outer surface of the capillary
basement membrane
All the layers are richly endowed with fixed negative charges that hinder the
passage of plasma proteins. Filterability of solutes is inversely related to their size.
In certain kidney diseases, the negative charges on the basement membrane are
lost even before there are noticeable changes in kidney histology, a condition referred
to as minimal change nephropathy.
As a result of this loss of negative charges on the basement membranes, some of
the lower-molecular-weight proteins, especially albumin, are filtered and appear in
the urine, a condition known as proteinuria or albuminuria.

DETERMINANTS OF GFR:
The GFR is determined by (1) the sum of the hydrostatic and colloid osmotic forces
across the glomerular membrane, which gives the net filtration pressure, and
(2) the glomerular capillary filtration coefficient, Kf.
Expressed mathematically, the GFR equals the product of Kf and the net filtration
pressure:
GFR = Kf Net filtration pressure
Net filtration pressure:
(1) hydrostatic pressure inside the glomerular capillaries (glomerular hydrostatic
pressure, PG), which promotes filtration;
(2) the hydrostatic pressure in Bowmans capsule (PB) outside the capillaries, which
opposes filtration;
(3) the colloid osmotic pressure of the glomerular capillary plasma proteins (pG),
which opposes filtration; and
(4) the colloid osmotic pressure of the proteins in Bowmans capsule (pB), which
promotes filtration.
REGULATION OF GFR RATE:
Renal autoregulation
Myogenic mechanism
Tubuloglomerular feedback
Neural regulation

Hormone regulation

Angiotensin II
Atrial natriuretic peptide (ANP)
TUBULAR REABSORPTION:
Reabsorption of filtered water and solutes from the tubular lumen across the tubular
epithelial cells, through the renal interstitium, and back into the blood.
Solutes are transported through the cells (transcellular route) by passive diffusion or
active transport, or between the cells (paracellular route) by diffusion.

 Water is transported through the cells and between the tubular cells by osmosis.
Transport of water and solutes from the interstitial fluid into the peritubular capillaries
occurs by ultrafiltration (bulk flow).
PRIMARY ACTIVE TRANSPORT:
The sodium-potassium pump transports sodium from the interior of the cell across
the basolateral membrane, creating a low intracellular sodium concentration and a
negative intracellular electrical potential.
The low intracellular sodium concentration and the negative electrical potential
cause sodium ions to diffuse from the tubular lumen into the cell through the brush
border.
SECONDARY ACTIVE TRANSPORT:
The upper cell shows the co-transport of glucose and amino acids along with
sodium ions through the apical side of the tubular epithelial cells, followed by
facilitated diffusion through the basolateral membranes.
The lower cell shows the counter-transport of hydrogen ions from the interior of the
cell across the apical membrane and into the tubular lumen; movement of sodium
ions into the cell, down an electrochemical gradient established by the sodiumpotassium pump on the basolateral membrane, provides the energy for transport of
the hydrogen ions from inside the cell into the tubular lumen.
For most substances that are actively reabsorbed or secreted, there is a limit to the
rate at which the solute can be transported, often referred to as the transport
maximum.
This limit is due to saturation of the specific transport systems involved when the
amount of solute delivered to the tubule (referred to as tubular load) exceeds the
capacity of the carrier proteins and specific enzymes involved in the transport
process.
PRIMARY TRANSPORT CHARACTERISTICS OF THE PROXIMAL TUBULE:
The proximal tubules reabsorb about 65% of the filtered sodium, chloride,
bicarbonate, and potassium and essentially all the filtered glucose and amino acids.
The proximal tubules also secrete organic acids, bases, and hydrogen ions into
thetubular lumen.

TRANSPORT CHARACTERISTICS OF THE THIN DESCENDING LOOP OF HENLE

AND THE THICK ASCENDING SEGMENT OF THE LOOP OF HENLE:
The descending part of the thin segment of the loop of Henle is highly permeable to
water and moderately permeable to most solutes but has few mitochondria and little
or no active reabsorption.
The thick ascending limb of the loop of Henle reabsorbs about 25 per cent of the
filtered loads of sodium, chloride, and potassium, as well as large amounts of calcium,
bicarbonate, and magnesium.
This segment also secretes hydrogen ions into the tubular lumen.
TRANSPORT CHARACTERISTICS OF THE EARLY DISTAL TUBULE AND THE LATE
DISTAL TUBULE AND COLLECTING TUBULE
The early distal tubule has many of the same characteristics as the thick ascending
loop of Henle and reabsorbs sodium, chloride, calcium, and magnesium but is
virtually impermeable to water and urea.
The late distal tubules and cortical collecting tubules are composed of two distinct
cell types, the principal cells and the intercalated cells.
The principal cells reabsorb sodium from the lumen and secrete potassium ions into
the lumen.
The intercalated cells reabsorb potassium and bicarbonate ions from the lumen and
secrete hydrogen ions into the lumen. The reabsorption of water from this tubular
segment is controlled by the concentration of antidiuretic hormone.
TRANSPORT CHARACTERISTICS OF THE MEDULLARY COLLECTING DUCT:
The medullary collecting ducts actively reabsorb sodium and secrete hydrogen ions
and are permeable to urea, which is reabsorbed in these tubular segments.
The reabsorption of water in medullary collecting ducts is controlled by the
concentration of antidiuretic hormone.
REGULATION OF TUBULAR REABSORPTION:
Regulation of sodium, k balance:
High-sodium diet decreases plasma aldosterone, which tends to decrease potassium
secretion by the cortical collecting tubules. However, the high-sodium diet
simultaneously increases fluid delivery to the cortical collecting duct, which tends to
increase potassium secretion.

 The opposing effects of a high sodium diet counterbalance each other, so that there
is little change in potassium excretion.
Excretion of Metabolic Waste Products, Foreign Chemicals, Drugs, and
Hormone Metabolites.
urea(from the metabolism of amino acids),
creatinine (from muscle creatine),
uric acid (from nucleic acids),
end products of hemoglobin breakdown (such as bilirubin),
and metabolites of various hormones.
Regulation of Water and Electrolyte Balances.
maintenance of homeostasis,
If intake exceeds excretion, the amount of that substance in the body will increase.
If intake is less than excretion, the amount of that substance in the body will
decrease.
Regulation of Arterial Pressure.
kidneys play a dominant role in long-term regulation of arterial pressure by
excreting variable amounts of sodium and water.
The kidneys also contribute to short-term arterial pressure regulation by secreting
vasoactive factors or substances, such as renin, that lead to the formation of
vasoactive products
Regulation of Acid-Base Balance.
The kidneys contribute to acid-base regulation, along with the lungs and body fluid
buffers, by excreting acids and by regulating the body fluid buffer stores.
sulfuric acid
phosphoric acid

REGULATION OF ERYTHROCYTE PRODUCTION.

The kidneys secrete erythropoietin, which stimulates the production of red blood
cells
stimulus for erythropoietin secretion by the kidneys is hypoxia.
In people with severe kidney disease or who have had their kidneys removed and
have been placed on hemodialysis, severe anemia develops.
Regulation of 1,25Dihydroxyvitamin D3 Production.:
kidneys produce the active form of vitamin D, 1,25- dihydroxyvitamin D3 (calcitriol)
Calcitriol is essential for normal calcium deposition in bone and calcium
reabsorption by the gastrointestinal tract.
calcitriol plays an important role in calcium and phosphate regulation.
GLUCOSE SYNTHESIS.
The kidneys synthesize glucose from amino acids and other precursors during
prolonged fasting, a process referred to as gluconeogenesis.
With complete renal failure, enough potassium, acids, fluid, and other substances
accumulate in the body to cause death within a few days, unless clinical interventions
such as hemodialysis are initiated to restore, at least partially, the body fluid and
electrolyte balances.
Less known facts about kidneys
Fit kidney works 24 hours a day /7 days a week to fresh the blood.
Kidney will continue performing till they have mislaid 75-80% of their function.
Just one donated Kidney is required to substitute two failed Kidneys.

LIVER
The liver is a discrete organ .
Heaviest gland
Weighs about 1.4 kgs
Occupies most of right hypochondrium
ANATOMY OF THE LIVER:
The liver is almost completely covered by visceral peritoneum and is completely
covered by a dense irregular connective tissue
The liver is divided into two principal lobesa large right lobe and a smaller left
lobeby
the falciform ligament, a fold of the mesentery
Although the right lobe is considered by many anatomists to include an inferior
quadrate lobe and a posterior caudate lobe based on internal morphology, the
quadrate and caudate lobes more appropriately belong to the left lobe. The falciform
ligament extends from the undersurface of the diaphragm between the two principal
lobes of the liver to the superior surface of the liver, helping to suspend the liver in
the abdominal cavity.
In the free border of the falciform ligament is the ligamentum teres (round
ligament), a remnant of the umbilical vein of the fetus
HISTOLOGY OF THE LIVER
The basic functional unit of the liver is the liver lobule
contains 50,000 to 100,000 individual lobules
HEPATOCYTES :
major functional cells of the liver
80% of the volume of the liver
hepatic laminae
Hepatocytes secrete bile

BILE CANALICULI :
These aresmall ducts between hepatocytes that collect bile produced bythe
hepatocytes
. From bile canaliculi, bile passes into bileductules and then bile ducts. The bile
ducts merge and eventuallyform the larger right and left hepatic ducts, whichunite
and exit the liver as the common hepatic duct
The common hepatic duct joins the cystic duct from the gallbladder to form the
commonbile duct.

HEPATIC SINUSOIDS
highly permeable blood capillaries between rows of hepatocyte
Hepatic sinusoids converge and deliver blood into a central vein
From central veins the blood flows into the hepatic veins
drain into the inferior vena cava
stellate reticuloendothelial (Kupffer) cells
PORTAL TRIAD
a bile duct,
branch of the hepatic artery,
branch of the hepatic vein
HEPATIC LOBULE
hepatic lobule is shaped like a hexagon
central vein, and radiating out from it are rows of hepatocytes and hepatic
sinusoids.
hepatic lobules surrounded by thick layers of connective tissue
PORTAL LOBULE
portal lobule is triangular in shape
three imaginary straight lines that connect three central veins that are closest to
the portal triad
HEPATIC ACINUS
Each hepatic acinus is an approximately oval mass that in- cludes portions of two
neighboring hepatic lobules

 short axis-portal triad

long axis two imaginary curved lines, which connect the two central veins
Hepatocytes in the hepatic acinus are arranged in three zones
zone 1
Zone 2
Zone 3
Blood Supply of the Liver
The Liver Has High Blood Flow and Low Vascular Resistance.
Cirrhosis of the Liver Greatly Increases Resistance to Blood Flow.
The Liver Functions as a Blood Reservoir
The Liver Has Very High Lymph Flow
High Hepatic Vascular Pressures Can Cause Fluid Transudation
Into the Abdominal Cavity from the Liver and Portal CapillariesAscites.
Regulation of Liver Mass Regeneration
The liver possesses a remarkable ability to restore itself
Partial hepatectomy, in which up to 70 per cent of the liver is removed, causes the
remaining lobes to enlarge and restore the liver to its original size.
Control of this rapid regeneration of the liver is still poorly understood, but
hepatocyte growth factor (HGF)
transforming growth factor-, a cytokine secreted by hepatic cells, is a potent
inhibitor of liver cell proliferation and has been suggested as the main terminator of
liver regeneration
Hepatic Macrophage System Serves a Blood-Cleansing Function.
Blood flowing through the intestinal capillaries picks up many bacteria from the
intestines.
Kupffer cell, in less than 0.01 second the bacterium passes inward through the wall
of the Kupffercell to become permanently lodged therein until it is digested.

FUNCTIONS
many of its functions interrelate with one another.
(1) filtration and storage of blood
(2) Metabolism of carbohydrates, proteins, fats, hormones, and foreign chemicals
(3) formation of bile
(4) storage of vitamins and iron
(5) formation of coagulation factors.
Metabolic Functions of the Liver
Carbohydrate Metabolism
1. Storage of large amounts of glycogen
2. Conversion of galactose and fructose to glucose
3. Gluconeogenesis
4. Formation of many chemical compounds from
Fat Metabolism
1. Oxidation of fatty acids to supply energy for other body functions
2. Synthesis of large quantities of cholesterol, phospholipids, and most lipoproteins
3. Synthesis of fat from proteins and carbohydrates
Protein Metabolism
1. Deamination of amino acids
2. Formation of urea for removal of ammonia from the body fluids
3. Formation of plasma proteins
4. Interconversions of the various amino acids and synthesis of other compounds
from amino acids
The Liver Stores Iron as Ferritin.
greatest proportion of iron in the body is stored in the liver in the form of ferritin
The hepatic cells contain large amounts of a protein called apoferritin,

 When the iron in the circulating body fluids reaches a low level, the ferritin releases
the iron.
Apoferritin ferritin system of the liver acts as a blood iron buffer
The Liver Forms a Large Proportion of the Blood Substances Used in
Coagulation.
Fibrinogen
prothrombin
accelerator globulin
Factor VII
The Liver Removes or Excretes Drugs, Hormones, and Other Substances.
liver is well known for its ability to detoxify or excrete into the bile many drugs,
including sulfonamides, penicillin, ampicillin, and erythromycin.
several of the hormones secreted by the endocrine glands are either chemically
altered or excreted by the liver
Liver damage can lead to excess accumulation of one or more of these hormones
Jaundice Excess Bilirubin in the Extracellular Fluid
Jaundice refers to a yellowish tint to the body tissues, including a yellowness of the
skin as well as the deep tissues.
cause of jaundice is large quantities of bilirubin in the extracellular fluids
normal plasma concentration of bilirubin, 0.5 mg/dl of plasma.
The common causes of jaundice are (1) increased destruction of red blood cells,
with rapid release of bilirubin i
(2) obstruction of the bile ducts or damage to the liver cells
These two types of jaundice are called, respectively
hemolytic jaundice and
obstructive jaundice.

Diagnostic Differences Between Hemolytic and Obstructive Jaundice.

In hemolytic jaundice, almost all the bilirubin is in the free form
in obstructive jaundice, it is mainly in the conjugated form.
van den Bergh reaction
Total obstructive jaundice, tests for urobilinogen in the urine are completely
negative.
severe obstructive jaundice, significant quantities of conjugated bilirubin appear in
the urine.
Liver function tests
ALKALINE PHOSPHOTASE
Alkaline phosphatase is present in high concentration in growing bone, in bile, and
in the placenta.
Normal level: 30 to 115 U/l.
Increased
A. In children (growing bone).
B. Osteoblastic bone disease
C. Hepatic disease
D. Pregnancy.
Decreased:
Hypophosphatasia
hypothyroidism
malnutrition
Bilirubin
Destruction of haemoglobin yields bilirubin,
Bilirubin accumulates in the plasma when liver insufficiency exists, biliary
obstruction is present, or the rate of hemolysis increases.
Normal level: 0.2 to 1.2 mg/dl.

Increased
Direct and indirect forms of serum bilirubin are elevated in acute or chronic hepatitis,
biliary tract obstruction , toxic reactions to many drugs, chemicals and toxins ,and
Dubin-Johnson and Rotors syndrome
Aspartate aminotransferase (AST)
Aspartate aminotransferase (AST), Alanine aminotransferase (ALT), lactate
dehydrogenase (LDH) are intracellular enzymes involved in amino acid or
carbohydrate metabolism.
Normal: 5 to 25 U/l.
Increased:
Myocardial infarction (especially AST), acute infectious hepatitis ,cirrhosis of the liver
and metastatic and primary liver neoplasm
Decreased:
Pyridoxine (vitamin B6), deficiency (often as a result of repeated hemodialysis), renal
insufficiency, and pregnancy
Jaundice Excess Bilirubin in the Extracellular Fluid
Jaundice refers to a yellowish tint to the body tissues, including a yellowness of the
skin as well as the deep tissues.
cause of jaundice is large quantities of bilirubin in the extracellular fluids
normal plasma concentration of bilirubin, 0.5 mg/dl of plasma.
The common causes of jaundice are
(1) increased destruction of red blood cells, with rapid release of bilirubin
(2) obstruction of the bile ducts or damage to the liver cells
These two types of jaundice are called, respectively
hemolytic jaundice and
obstructive jaundice

Drugs to be avoided in cirrhosis

NSAIDs, ACE inhibitors :
Reduced renal blood flow
Hepatorenal failure
Ulceration Bleeding varices
Codeine Narcotics Anxiolytics :
Constipation
Hepatic encephalopathy
, drug accumulation
drug-induced hepatotoxicity
Cholestasis Chlorpromazine

Cholestatic hepatitis

Acute hepatitis

High-dose oestrogens
NSAIDs
Co-amoxiclav
Statins
Rifampicin
Isoniazid

Clinical significance
Halitosis :
in liver insufficiency such as cirrhosis, ammonium will be accumulated in blood and
will be exhaled
In kidney insufficiency , primarly caused by chronic glomerularnephritis will lead to
increased uric acid level in blood

Conclusion
Kidney and liver the functions of these organs are so vast that they alone, are
testaments to the ingenuity of the body.
The primary function of the liver, kidneys being expulsion of toxins that result from
the body's metabolism of various dietary and other harmful chemicals and hence
these organs play a major role in maintaining homeostasis in the body.

References
Guyton And Hall, Textbook Of Medical Physiology, W b Saunders, 11 th Edition
Tortora GJ ,Grabowsk, Textbook Of Medical Physiology, harper Collins, 8 th Edition .
Davidsons principles and practice of medicine, 20th edition

1)Management of renal failure patient

a)
Periodontal disease was recently reported in 100% of all patients scheduled for
renal dialysis
co-ordination with the patient's physician.
infection control protocol may involve extraction of teeth with poor or hopeless
prognosis, scaling and root planing, restoration of carious lesions and endodontic
treatment where needed.
prophylactic antibiotics
Antimicrobial mouthrinses
2) SGOT, SGPT
a) formerly SGOT- Aspartate aminotransferase (AST), Alanine aminotransferase (ALT),
lactate dehydrogenase (LDH) . Elevation of concentrations of these enzymes in blood
indicate necrosis or disease especially of these tissues. Normal: 5 to 25 U/I
Increased:
Myocardial infarction (especially AST), acute infectious hepatitis (ALT usually
elevated more than AST), cirrhosis of the liver (AST usually elevated more than ALT),
and metastatic and primary liver neoplasm
Decreased: Pyridoxine (vitamin B6), deficiency (often as a result of repeated
hemodialysis), renal insufficiency, and pregnancy.
Decreased:
Pyridoxine (vitamin B6), deficiency (often as a result of repeated hemodialysis), renal
insufficiency, and pregnancy.
Alanine aminotransferase (ALT)
a) (formerly SGPT) -Normal level: 5 to 30 U/l.
Increased:
Liver disease (more specific than AST), pancreatitis, biliary obstruction

3)Drug metabolism
a) The primary site for drug metabolism is liver
All orally adminnstered drugs are exposed to drug metabolizing enzymes in liver
Kidneys are responsible for excreting all water soluble substances.
The amount of drug present in the urine is sumtotal of glomerular filteration, tubular
reabsorption, tubular secretion
most common pathway for drug metabolism Cytochrome-P450
4) halitosis in liver and kidney disease
a) in liver insufficiency such as cirrhosis, ammonium will be accumulated in blood
and will be
exhaled, pleasantly sweet smell in odor qualification.
In kidney insufficiency , primarly caused by chronic glomerularnephritis will lead to
increased uric acid level in blood, fishy smell in odor qualification.