Vous êtes sur la page 1sur 88

URINARY SYSTEM

Organ sistem perkemihan


Ginjal/Kidneys
Ureter/Ureters
Kandung kemih
(urinary bladder)
Uretra/Urethra

Figure 15.1a
Copyright2003PearsonEducation,Inc.publishingasBenjaminCummings

GINJAL

1.
2.
3.
4.

Fungsi Ginjal :
Ekskresi produk sisa metabolik & bahan
kimia asing.
Pengaturan konsentrasi osmolalitas cairan
tubuh & konsentrasi elektrolit.
Pengaturan keseimbangan asam-basa
darah.
Pengaturan keseimbangan air & elektrolit.

5.
6.

Pengaturan tekanan darah


Sekresi hormon :
Renin;Erithropoietin; 1,25
dihidroksikolekalsiferol.

Anatomi Fisiologi Ginjal


Bentuk = seperti kacang, dengan sisi

cekung menghadap ke medial.


Ukuran = 11,5 cm (panjang) x 6 cm (lebar)
x 3,5 cm (tebal).
Berat = 150-170 gr atau 0,4%BB.
Letak = dinding posterior abdomen, di luar
rongga peritoneum.

Kutup atas ginjal kanan terletak


setinggi costa 12, kutup atas
ginjal kiri terletak setinggi costa
11.
Hilum = sisi medial ginjal yang
merupakan daerah lekukan
tempat lewat arteri & vena
renalis, cairan limfatik, suplai
saraf, ureter.

1.
2.

Ginjal dibagi atas 2 bagian (dari atas ke


bawah) :
Korteks (bagian luar)
Medulla (bagian dalam)

Pelvic space
Renal artery
Renal vein

Pelvis

Ureter

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Structure of the Kidney

Outer cortex:

Contains many
capillaries.

Medulla:

Renal pyramids
separated by
renal columns.
Pyramid
contains minor
calyces which
unite to form a
major calyx.

Major calyces form renal pelvis.


Renal pelvis collects urine.
Transports urine to ureters.

Suplai Darah Ginjal


21%

dari curah jantung = 1200ml/mt.

Ada 2 bentuk kapiler :


1. Kapiler glomerulus
2. Kapiler peritubulus

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Renal Blood Vessels

Afferent arteriole:

Glomeruli:

Capillary network that produces filtrate


that enters the urinary tubules.

Efferent arteriole:

Delivers blood into the glomeruli.

Delivers blood from glomeruli to


peritubular capillaries.

Peritubular capillaries:

Deliver blood to vasa recta.

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Renal Blood Vessels

(continued)

Insert fig. 17.5

Nefron
Unit

fungsional ginjal.(1 juta nefron


1 ginjal)
Bertanggung jawab dlm
pembentukan urine.

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Nephron

Functional unit
of the kidney.
Consists of:

Blood vessels:

Vasa recta.
Peritubular
capillaries.

Urinary
tubules:

PCT.
LH.
DCT.
CD.

The nephron
The nephron is the functional unit of the kidney
Each region is composed of cells that are suited to perform specific transport functions

Distal convoluted
tubule
Proximal
convoluted
tubule
Collecting duct

Ascending
thin limb of
loop of Henl

Ascending thick limb


of loop of Henl

Vascular supply to the nephron


Proximal convoluted
tubule
Glomerulus
Arcuate vein

Efferent arteriole
Afferent arteriole
Distal convoluted tubule

Arcuate artery
Collecting duct
Vasa recta
Thick ascending limb
of the loop of Henl
Descending limb
loop of Henl

Thin ascending limb


of the loop of Henl

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Nephron Tubules

Glomerular
capsule.
Proximal
convoluted
tubule (PCT).
Descending and
ascending
limbs of Loop of
Henle (LH).
Distal
convoluted
tubule (DCT).
Collecting duct
(CD).

Glomerulus
Merupakan invaginasi

tumpukan kapiler ke
ujung buntu nefron
(capsula Bowman).
Glomerulus dan Capsula
bowman disebut sebagai
Renal corpuscle.

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Glomerular Capsule

Bowmans
capsule:

Surrounds the
glomerulus.

Location where
glomerular
filtration
occurs.

Filtrate passes
into the urinary
space into PCT.

Insert fig. 17.6

Nefron terbagi atas 2 bentuk :


Juxtameduler nefron.
2. Cortical nefron.
1.

Cortical nefron

Juxtamedular n.

Letak glomerulus di
luar cortex
Loop of henle
pendek

Di cortex renal,
sebelah dalam
dekat medulla.
Loop of henle
panjang
kapiler peritubuler
khusus vasa recta)

Superficial and juxtamedullary nephrons


Superficial
nephrons:
short loop of
Henl
peritubular
capillaries carry
nutrients to tubule
Juxtamedullary
nephrons:
glomerulus larger
long loop of
Henl extending
deep into medulla
efferent arterioles
also form a vasa
recta

Capsule

PT
Gl

Cortex

DCT
TAL

Proximal
convoluted tubule
Distal convoluted
tubule
Glomerulus

DTL
ATL

Distal tubule, thick


ascending limb
CT

Medulla

Descending Loop
thin limb
of
Henl
Ascending
thin limb
Collecting duct

Mekanisme Dasar Pembentukan


Urine
1.
2.
3.
4.

Filtrasi
Reabsorpsi
Sekresi
Ekskresi

THREE BASIC RENAL


PROCESSES
Glomerular Filtration: Filtering of blood
into tubule forming the primitive urine
Tubular Reabsorption: Absorption of
substances needed by body from
tubule to blood
Tubular Secretion: Secretion of
substances to be eliminated from the
body into the tubule from the blood

Glomerular Filtration
First step in urine formation called
primary urine.
180 liters/day filtered
Entire plasma volume filtered 65
times/day
Blood Ultrafiltration dimana sel-sel
darah dan molekul-molekul besar
protein tidak dapat melewati
membran filtrasi glomerulus.

GLOMERULAR FILTRATION
The glomerular filtration rate (GFR) is about 125 ml/min in a normal adult

The first step in the formation of urine is the production of a plasma ultrafiltrate.
The ultrafiltrate is cell and protein-free and the concentration of small solutes are
the same as in plasma.
The filtration barrier restricts movement of solutes on a basis of size and charge.
Molecules < 1.8 nm freely filtered; >3.6 nm not filtered
Cations are more readily filtered than anions for the same molecular radius.
Serum albumin has a radius if about 3.5 nm but its negative charge prevents its
filtration
In many disease processes the negative charge on the filtration barrier is lost
so that proteins are more readily filtered - a condition called proteinuria

Membran filtrasi glomerulus


1.

2.
3.

terdiri atas 3 lapisan :


Bagian luar : Sel-sel epitel
visceral Capsula bowman
yang mempunyai podosit
dan terdapat celah poripori.
Bagian tengah : Membran
basalis.
Bagian dalam : sel-sel
endotel yang mempunyai
fenestra.

Sel-sel mesangial : sel-sel endotel yang terletak


diantara lengkung-lengkung kapiler dan berfungsi
sebagai jalinan penyokong bukan merupakan
membran filtrasi glomerulus.

Structure of the Bowmans (glomerular) capsule


Parietal layer of
glomerular capsule

Afferent arteriole
Juxtaglomerular
cell

Capsule
space
Efferent arteriole
Proximal
convoluted
tubule
Endothelium
of glomerulus

Podocyte
Pedicel

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Glomerular Filtration Membrane


(continued)

Insert fig. 17.8

Bowmans capsules - with glomerulus

The filtration barrier - podocytes

basal
lamina

pedicel

filtration
slit

fenestrated
endothelium

basal
lamina
podocyte
filtration
slit
fenestrated
endothelium

secondary
process
(pedicel)

podocyte
primary cell body
process

The glomerulus - low magnification


Basement
membrane

Podocyte
process

Cap

Mesangial
cell

Mesangial
matrix
Cap
Cap
Basement
membrane
Bowmans
capsule

Fenestrations
Bowmans
space

Detailed structure of the filtration system

Endoth
cell
nucleus

Podocyte
process

Capillary
Basement
membrane

F
BM
E
Basement
membrane

Capillary

Capillary

Fenestrations

Fenestrations

Endoth
cell
nucleus

The filtration barrier - pedicels


Bowmans
space
pedicel

filtration
slit

capillary

Membran filtrasi glomerulus


mempunyai muatan negatif
disebabkan adanya
molekul-molekul anion pada
membrana basalisnya maka
albumin yang bersifat anion
tidak dapat masuk kedalam
ruang capsula bowman.

PHYSICAL FACTORS IN GLOMERULAR FILTRATION


Starlings forces are involved in
determining glomerular filtration
filtration depends on the balance
between hydraulic (P) and
osmotic () pressures across the
capillary membrane

PI

PC

Aff.Art.
At the glomerulus
The filtrative force is:
PGC - PBC
Opposed by an absorptive force
GC

Eff.Art.
PGC

GS
PBC

THE GLOMERULUS - THE STARLING EQUILIBRIUM


The glomerulus is unusual with respect to most capillary beds.

mm Hg
40

PGC-PBC

30
20
10
0

Glomerular hydrostatic
pressure, PGC, is high and
relatively constant
45 mmHg.
This is offset by a pressure
in Bowmans capsule PBC
10 mm Hg
Net filtrative force is:
35 mm Hg

aff. art

eff. art.

THE GLOMERULUS - THE STARLING EQUILIBRIUM

mm Hg
40

PGC-PBC
GS

30
20
10
0

Net filtration
force

aff. art

Glomerular hydrostatic pressure,


PGC, is high and constant
45 mmHg.
This is offset by a pressure in
Bowmans capsule PBC 10mmHg
Net filtrative force is: 35 mm Hg

Osmotic pressure, GS, 25


mm Hg.
Due to the large net filtration
of fluid GS increases along
the capillary to 35 mm Hg to
eff. art. achieve a balance of forces.

FILTRATIONFRACTION
Filtration fraction is an important expression of the extent of
glomerular filtration.
Glomerular filtration rate
It is the ratio: Filtration fraction =
Renal plasma flow
Renal blood flow
1250 ml/min
glomerulus

RPF
750 ml/min
Efferent
Arteriole
625 ml/min

GFR
125 ml/min

renal
vein

tubule
124 ml/min

Urine 1 ml/min

It is the fraction of
renal plasma flow
that is filtered at
the glomerulus

FILTRATIONFRACTION
anexample
Glomerular filtration rate (GFR)
is about:
125 ml/min
Renal blood flow
is about:
1250 ml/min
Renal plasma flow (RPF)
is about:
750 ml/min

Remember: plasma volume


is about 60% of total blood
volume

125
Thus, in this example filtration fraction is:
750

0.17

GFR and RPF can be measured separately using clearance methods

RENAL BLOOD FLOW (RBF)


Renal blood flow is 1.25 l/min -i.e. about 25% of the cardiac output
This is a very large flow relative to the weight of the kidneys (350 g)

RBF determines GFR

Flow, l/min
1.5

RBF also modifies solute and


water reabsorption and delivers
nutrients to nephron cells.

1.0

Renal blood flow is

0.5

autoregulated between 90 and


180 mm Hg by varying renal
vascular resistance (RVR)
i.e. the resistances of the
interlobular artery, afferent
arteriole and efferent arteriole

Renal blood flow

GFR
0

0
100
200
Arterial blood pressure, mm Hg

RENAL BLOOD FLOW - AUTOREGULATION


Autoregulation effectively uncouples renal function from arterial
blood pressure and ensures that fluid and solute excretion is constant.
Two hypotheses have been proposed to explain autoregulation
1. Myogenic hypothesis
When arterial pressure increases the renal afferent arteriole is stretched
Increase of

Flow

arterial pressure

increases

Remember:
Flow14
r

RENAL BLOOD FLOW - AUTOREGULATION


1. Myogenic hypothesis
When arterial pressure increases the renal afferent arteriole is stretched
Increase of

Flow

arterial pressure

increases

Vascular smooth muscle responds by contracting


thus increasing resistance
Increase of
vascular tone

Flow
returns to
normal

RENAL BLOOD FLOW - AUTOREGULATION


2. Tubuloglomerular
feedback
Alteration of tubular flow
(or a factor in the filtrate) is
sensed by the macula densa
of the juxtaglomerular
apparatus (JGA) and
produces a signal that alters
GFR.
It is unclear what is the
factor (NaCl reabsorption?)
or the nature of the signal
(renin?).

4. Ra
GFR
GFR

2. filtrate

3.signal from
JGA

GFR normal
= 125 ml/mnt
= 7,5 l/ jam
= 180 liter/hari

Volume urin = 1 1,5 liter/hari.

Komposisi filtrat glomerulus


Elektrolit : Na2+, K+, Ca2+, Mg2+,
HCO3-, Cl-, HPO4=.
Non elektolit : Glukosa, asam amino,
metabolit yang merupakan hasil akhir
metabolisme protein : urea, asam
urat & kreatinin.

Tubular Reabsorption
By passive diffusion
By primary active transport: Sodium
By secondary active transport:
Sugars and Amino Acids

Reabsorpsi Tubulus
Kapiler peritubuler menyerap ;
Air
Glukosa
Asam amino
Ion-ion
Penyerapan sebagian besar terjadi
pada proximal convulated tubule.

Zat yang tidak direabsorpsi

1.
2.
3.

Sisa metabolisme nitrogenous :


Urea
Uric acid
Creatinine
Air yang berlebihan.

Reabsorption

Proximal tubule 65% of filtered load reabsorbed


Loop of Henle 15%
Distal tubule 10%
Collecting duct 9.3%
Urinary loss 0.7%

125 ml
65%

15%

10%

9.3%
Urine 1ml/125 ml

Proximal Tubule
Most glucose, amino acids, water, and

bicarbonate are reabsorbed in first half


of tubule
Osmolarity doesnt change because
relative concentrations of H2O and Na+
dont change

Loop of Henle
Thin descending loop
Thin endothelial cell layer
Highly permeable to water
20% of water reabsorbed here

Thin ascending loop


Little reabsorption here

Thick ascending loop


Thick endothelial cell layer
25% of filtered Na+, Cl-, K+ reabsorbed here
Impermeable to water
Dilutes urine

Distal Tubule
Juxtaglomerular apparatus
1st segment is diluting segment
impermeable to water but not to ions
2nd segment is similar to collecting duct
Principal cells
Intercalated cells

Impermeable to urea

Sekresi (secretion)
=Kebalikan Reabsorpsi
Beberapa

zat berpindah dari peritubular


capillaries ke renal tubules.
Hydrogen & potassium ion
Creatinine
Zat-zat yang meninggalkan renal tubule
berpindah ke ureter.

Urine Formation
1-filtration
movement fluid
across the
filtration
membrane as a
result of pressure.

Urine Formation
2-Reabsorption
movement of
substances from the
filtrate back into the
blood

Urine Formation
3- Secretion
active
transport of
solutes into the
neprhon.

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Transport Process Affecting


Renal Clearance

Ability of the kidneys to remove


molecules from plasma and excrete
those molecules in the urine.
If a substance is not reabsorbed or
secreted, then the amount excreted
= amount filtered.
Quantity excreted = V x U

Quantity excreted = mg/min.


V = rate of urine formation.
U = inulin concentration in urine.

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Measurement of GFR

If a substance is neither reabsorbed nor


secreted by tubule:

The amount excreted in urine/min. will be equal


to the amount filtered out of the glomeruli/min.

Rate at which a substance is filtered by the


glomeruli can be calculated:
Quantity filtered = GFR x P

P = inulin concentration in plasma.

Amount filtered = amount excreted


GFR = V x U
P

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Renal Clearance of Inulin

Insert fig. 17.22

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Renal Plasma Clearance

Volume of plasma from which a


substance is completely removed
in 1 min. by excretion in the urine.
Substance is filtered, but not
reabsorbed:

All filtered will be excreted.

Substance filtered, but also


secreted and excreted will be:

> GFR (GFR = 120 ml/ min.).

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Renal Plasma Clearance


Renal plasma clearance = V x U
P

V = urine volume per min.


U = concentration of substance in urine
P = concentration of substance in plasma

Compare renal handling of various


substances in terms of reabsorption
or secretion.

Mekanisme Aliran Balik


(Countercurrent)

1.

2.

Bertanggung jawab untuk


konservasi air oleh ginjal, mencakup 2
proses dasar:
Aliran balik pemekat (multiplier) dalam
loop of henle.
Aliran balik penukar (exchanger) dalam
vasa recta.

Fungsi Utama Loop of Henle :


Membentuk

cairan interstisial dalam


medulla hiperosmotik dan membuat
cairan tubular yang keluar dari loop of
henle dan masuk ke dalam tubulus distal
hipoosmotik.

Fungsi utama vasa recta :


Mencegah

hilangnya perbedaan osmotik


dalam cairan interstisial medulla yang
telah diciptakan oleh loop of henle.

Ureter

Merupakan saluran yang menghubungkan


ginjal ke kandung kemih, yang merupakan
lanjutan renal pelvis.
Panjang 10-12 inchi.
Ureter memasuki kandung kemih melalui
bagian posterior dengan cara menembus
otot detrusor didaerah trigonum kandung
kemih

Dinding ureter terdiri dari otot polos &


dipersarafi oleh saraf simpatis &
parasimpatis.
Kontraksi peristaltik pada ureter ditingkatkan
oleh perangsangan parasimpatis & dihambat
oleh perangsangan simpatis.
Peristalsis dibantu gaya gravitasi akan
memindahkan urine dari ureter ke kandung
kemih.

Kandung Kemih
(Vesica Urinaria)

1.

2.

Berfungsi menampung/menyimpan urine


sementara.
Terdiri atas :
Badan (corpus) = bagian utama
kandung kemih dimana urine terkumpul.
Leher (kollum) = lanjutan dari badan
yang berbentk corong, berjalan secara
inferior dan anterior ke dalam daerah
segitiga urogenital & berhubungan
dengan urethra.

Dinding kandung kemih :

3 lapisan otot polos (detrusor


muscle)

Mucosa : transitional epithellium

Dinding : tebal & berlipat saat


kandung kemih kosong.
Trigone tiga
pembukaan :
1.Dua dari ureter
2.Satu ke urethra

Persarafan

N. pelvikus yang berhubungan dengan


medulla spinalis melalui pleksus sakralis
(S2 dan S3).
Saraf sensorik = regangan dinding
kandung kemih refleks berkemih.
Saraf motorik = parasimpatis berakhir pada
sel ganglion yang terletak dalam dinding
kandung kemih untuk mensarafi otot detrusor.

Urethra

Saluran berdinding tipis yang memindahkan


urine dari kandung kemih ke luar tubuh
degan gerak peristalsis.
Panjang : pria=8 inchi, wanita=1 inchi.
Pengeluaran urine diatur oleh dua katup
(sphincters)
Internal urethral sphincter (tanpa
sadari/involuntary)
External urethral sphincter
(disadari/voluntary)

Micturition reflex and urination

Urination coordinated by micturition reflex


Initiated by stretch receptors in wall of bladder
Urination requires coupling micturition reflex
with relaxation of external urethral sphincter

Copyright 2004 Pearson Education, Inc., publishing as Benjamin Cummings

Berkemih (Micturition/Voiding)
Kedua katup (sphincter) otot harus
terbuka agar dapat berkemih
Internal urethral sphincter : direlakskan
setelah peregangan kandung kemih
Pengkatifan ini berasal dari impulse
dikirim ke spinal cord dan kemudian
balik melalui saraf pelvic splanchnic
External urethral sphincter : harus
direlakskan secara sadar
Copyright2003PearsonEducation,Inc.publishingasBenjaminCummings

Neuroanatomy of Micturition
Storage Stability and good
compliance of Bladder
Empty Contraction of detrusor and
opening of Urethra
Parasympathetic - Pelvic nerve
Sympathetic - Hypogastric nerve
Somatic nerves- Pudendal nerve

Neuroanatomy of Micturition
Micturition reflex center sacral
cords 2-4
Micturition control center pons
Sensory motor center frontal lobe
Limbic system
Cerebellum, Basal ganglia

Anatomy of the lower urinary tract


and its innervation

Stanton BA & Koeppen BM:


The Kidney in Physiology,
Ed. Berne & Levy, Mosby, 1998

2934

MICTURITION REFLEX
Bladder fills

+
Stretch receptors
Spinal Cord

Parasympathetic
nerve
Bladder contracts

Internal urethral
sphincter opens

Only the external urethral sphincter is controlled voluntarily

The Micturition Reflex

Figure 26.21

Mekanisme urine yang :

Hipotonis :
Banyak minum Vol. ECF
Sekresi ADH Reabsorbsi air
Diuresis.
Hipertonis
Sedikit minum Vol. ECF
Sekresi ADH Reabsorbsi air
Urine Hipertonis (Pekat).

Organs for the Collection and


storage of Urine

Figure 26.19a

Organs for the Collection and


storage of Urine

Figure 26.19b

Pemeriksaan Diagnostik Pada


Fungsi Ginjal :
Urinalisa
2. Radiologi
3. USG
1.

Urinalisa
Makroskopik :
Bau

Mikroskopik
Leukosit

:Eritrosit : Silinder :
Kristal :

: Amoniak
Warna : Kuning jernih

Kimiawi

pH : 4,5 - 8
Berat jenis :
1,003 1,035
Proteinuria : Glukosauria : -

Radiologi :

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Kidney Diseases

Acute renal failure:

Ability of kidneys to excrete wastes and regulate


homeostasis of blood volume, pH, and
electrolytes impaired.

Rise in blood [creatinine].


Decrease in renal plasma clearance of creatinine.

Glomerulonephritis:

Inflammation of the glomeruli.


Autoimmune disease by which antibodies have
been raised against the glomerulus basement
membrane.

Leakage of protein into the urine.

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Kidney Diseases

Renal insufficiency:

Nephrons are destroyed.


Clinical manifestations:

(continued)

Salt and H20 retention.


Uremia.
Elevated plasma [H+] and [K+].

Dialysis:

Separates molecules on the basis of the


ability to diffuse through selectively
permeable membrane.