Overview of

Kidney Anatomy
& Physiology

Morphology of Kidney
Kidneys are a pair of
organs
located behind the
abdomen
About 300 g
4or 5 inches long
Size of a fist

Functions of the Kidney

Clears urea, a nitrogenous waste product

from the metab0lism of amino acids.
Regulate electrolytes in the human blood (eg.
Na+, K+, Ca2+)
Regulate arterial pressure
Regulate acid-base balance
Regulate glucose synthesis
Release erythropoietin for erythrocyte
production.
Produce vitamin D important in Ca2+
regulation.

Gross Anatomy of the Kidney

Parts of the
kidney

Fibrous capsule
Renal cortex
Renal Medulla
Renal Pelvis
Renal Sinus
Renal papilla

Functional unit of KidneyNephron

Nephron is the basic structural and functional unit of

the kidney

Each kidney consists of about 1-1.2 million nephrons

Its chief function is to regulate water and soluble

substances by filtering the blood, reabsorbing what
is needed and excreting the rest as urine

Types of Nephrons:
- Cortical nephrons
- Juxtamedullary nephrons

Parts of a Nephron
Glomerular

apparatus

Proximal tubule
Loop of Henle
Distal tubule
Collecting ducts

Physiology of the
Kidney

Urine formation

Three process for urine formation

include:

Glomerular Filtration

Tubular Reabsorption

Tubular Secretion

Glomerulus
Filters fluid and solutes from blood

Proximal convoluted tubule

Reabsorbs Na, K, Cl, HCO, urea, glucose & amino
Filtrate continues

Loop of Henle
Reabsorbs Na, K & Cl
Blocks reabsorption of H2O
Dilutes/ Concentrates Urine

Distal Tubule
Na, K, Ca, PO4 selectively reabsorbed
H2O reabsorbed in presence of Antidiuretic Hormone (ADH)
Filtrate continues

Collecting Duct
Rebasorption similar to distal tubule
HCO3 & H reabsorbed/secreted to acidify urine
Filtrate leaves hyperosmotic / hypoosmotic depending on the body
requirements

DIALYSIS

Indications of dialysis

Pericarditis or pleuritis
Progressive uremic encephalopathy or
neuropathy (AMS, asterixis, myoclonus,
seizures)
Bleeding diathesis
Fluid overload unresponsive to diuretics
Metabolic disturbances refractory to medical
therapy (hyperkalemia, metabolic acidosis,
hyper- or hypocalcemia, hyperphosphatemia)
Persistent nausea/vomiting, weight loss, or
malnutrition
Toxic overdose of a dialyzable drug

Goals of Dialysis
Solute clearance
Diffusive transport (based on countercurrent
flow of blood and dialysate)
Convective transport (solvent drag with
ultrafiltration)
Fluid removal

Different types of dialysis

1.
2.

Haemodialysis (HD)
Peritoneal Dialysis
- Both works on similar principles:
Movement of solute or water across
a semi-permeable membrane
(dialysis membrane)

Selection for HD/PD

Clinical

condition

Lifestyle
Patient

competence/hygiene (PD high risk of infection)

Affordability

/ Availability

Haemodialysis
Dialysis

process occurs outside the

body in a machine
The dialysis membrane is an artificial
one called as Dialyser
The dialyser removes the excess
fluid and wastes from the blood and
returns the filtered blood to the body
Haemodialysis needs to be
performed thrice a week
Each session lasts around 3-6 hrs

Requirements for
Haemodialysis
Good

access to patients circulation

Good cardiovascular status
(dramatic changes in BP may occur)

Haemodialysis access
2

types of access for HD:

Must provide good flow

Reliable access

A fistula: arterio-venous (AV)

Vascular Access Catheter

Aterio-venous fistula
Preferred form of dialysis
access
Typically end-to-side vein-toartery anastamosis
Types
Radiocephalic (first choice)
Brachiocephalic (second
choice)
Brachiobasilic (third
choice, requires
superficialization of basilic
vein, i.e. transposition)

Vascular Access Catheter

Double lumen plastic tube

May be placed in Jugular,
Subclavian or Femoral vein
May be temporary or permanent
Temporary awaiting fistula or
maturation
Permanent poor vessels for
fistula creation e.g. children and
diabetics
Catheters must be kept clean,
dry and dressed to prevent
infection

Peritoneal Dialysis (PD)

Uses natural membrane (peritoneum) for dialysis

Access is by PD catheter, a soft plastic tube

Catheter and dialysis fluid may be hidden under

clothing

Suitability
Excludes patients with prior peritoneal scarring
e.g. peritonitis, laparotomy
Excludes patients unable to care for self

Types of Peritoneal dialysis

Continuous

Ambulatory Peritoneal
Dialysis (CAPD)

Automated

peritoneal Dialysis (APD)

Continuous Ambulatory Peritoneal

Dialysis

Dialysis takes place 24hrs a day, 7 days a

week
Patient is not attached to a machine for
treatment
Exchanges are usually carried out by patient
after training by a CAPD nurse
Most patients need 3-5 exchanges a day i.e.
4-6 hour intervals (Dwell time) 30 mins per
exchange
May use 2-3 litres of fluid in abdomen
No needles are used
Less dietary and fluid restriction

CAPD Exchange

Automated peritoneal Dialysis

Uses

a home based machine to perform

exchanges
Overnight treatment whilst patient sleeps
The APD machine controls the timing of
exchanges, drains the used solution and
fills the peritoneal cavity with new solution
Simple procedure for the patient to perform
Needs about 8-10 hrs
Portable machines with in-built safety
features and requires electricity to operate

Acute Complications of
Dialysis
Hypotension
Cramps
Nausea

and vomiting
Headache
Chest pain
Back pain
Itching
Fever and chills

Acute complications of
Dialysis
Hemolysis
Port wine appearance of the blood in the venous line, a

falling hematocrit, or complaints of chest pain, SOB,

and/or back pain
Usually due to dialysis solution problems (overheating,

hypotonicity, and contamination with formaldehyde,

bleach, chloramine, etc)
Treatment includes discontinuation of dialysis without

blood return to the patient, and evaluation for

hyperkalemia with medical treatment as necessary

Acute complications of
Dialysis
Arrhythmias
Usually seen during and between

dialysis treatments
Controversial whether due to
disturbances in plasma potassium
Treatment approach is similar to the
non-dialysis population, except for
medication dosing adjustments

Understanding of Anemia

Definition of Anemia

Deficiency in the oxygen-carrying capacity

of the blood due to a diminished
erythrocyte mass.
Causes
1. Erythrocyte loss (bleeding)
2. Decreased Erythrocyte production
1. -Low erythropoietin
2. - Decreased marrow response to
erythropoietin
3. Increased Erythrocyte destruction
(hemolysis)

Anemia - laboratory
diagnosis
Hemoglobin (g/dL)
Hematocrit (%)
RBC Count (106/mm3)
Reticulocytes
WBC (cells/mm3)
MCV (fL)
MCH (pg/RBC)
MCHC (g/dL of RBC)
RDW

(%)

Men

Women

14-17.4
42-50%
4.5-5.9

12.3-15.3
36-44%
4.1-5.1

1.6 0.5%
1.4 0.5%
~4,000-11,000
80-96
30.4 2.8
34.4 1.1
11.7-14.5%

Symptoms of Anemia

Decreased oxygenation
Exertional dyspnea
Dyspnea at rest
Fatigue
Lethargy, confusion
Bounding pulses
Decreased volume
Muscle cramps
Fatigue
Postural dizziness
syncope

Physical examination
Pallor (may be jaundiced think hemolytic)
Tachycardia, bounding pulses
Systolic flow murmur
Glossitis
Angular cheilosis
Decreased vibratory sense/ joint position
sense (B12 deficiency, w/ or w/o
hematologic changes)
Ataxia, positive Romberg sign (severe
B12/folate deficiency)

Differential diagnosis
Anemia
Hypothyroidism
Depression
Cardiac (congestive heart failure, aortic

stenosis)
Pulmonary causes of SOB/DOE
Chronic fatigue syndrome, others

Special considerationsAnemia

In case of acute bleeding

Drop in Hgb or Hct may not be shown until 36 to 48

hours after acute bleed (even though patient may
be hypotensive)

In cases of Pregnancy

In third trimester, RBC and plasma volume are

expanded by 25 and 50%, respectively.
Labs will show reductions in Hgb, Hct, and RBC
count, often to anemic levels, but according to RBC
mass, they are actually polycythemic

In case of Volume Depletion

Patients who are severely volume depleted may not

show anemia until after rehydrated

Causes of Anemia
Anemia due to Bleeding
1.
2.

Chronic (gastrointestinal, menstrual)

Acute/Hemodynamically significant:
- Gastrointestinal
- Retroperitoneal

Causes of Anemia
Anemia due to Low Erythropoietin
Kidney Disease
Normochromic, normocytic
Low reticulocyte count
Frequently, peripheral smear in uremic patients

show burr cells or echinocytes

Target hemoglobin for patients on dialysis is 11
to 12 g/dL
Administer erythropoietin or darbopoietin weekly
Good Iron stores must be maintained

Causes of Anemia
Anemia due to Decreased response to
Erythropoeitin
Iron-Deficiency
Folate Deficiency
Vitamin B12 Deficiency
Anemia of Chronic Disease

Causes of Anemia
Anemia due to Destruction of Red Blood Cells
1. Hemoglobinopathies
-Sickle Cell Anemia
2. Aplastic Anemia
-Decrease in all lines of cells hemoglobin,
hematocrit, WBC, platelets
-Parvovirus B19, EBV, CMV
-Acquired aplastic anemia
3.Hemolytic Anemia

Treatment options

In

Patient
- Erythropoietic stimulating proteins
-Iron supplementation (nutritional)
- Increase threshold for transfusion
- Blood transfusion
- Blood substitutes
Transition to outpatient
- Dietary changes
- Iron supplementation
- Erythropoeitic stimulating proteins