The Renal System at a Glance E-Book

Christopher O'Callaghan

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: At a Glance
• Sprache: Englisch

Seitenzahl: 317

Veröffentlichungsjahr: 2016

Beschreibung

Highly Commended in Internal medicine in the 2017 BMA Medical Book Awards

The Renal System at a Glance is a highly illustrated and practical guide to the structure and function of the kidney, renal, and urinary system. It also covers related disorders and abnormalities and their treatment.

Fully updated to reflect the many exciting new developments in the understanding of nephrology, this new edition has been restructured to better integrate basic science and clinical examples to the medical school curricula. New chapters on glomerular filtration and global kidney medicine are included, while the latest guidance and approaches to acute kidney injury, chronic kidney diseases, and renal replacement therapy have also been incorporated.

The Renal System at a Glance:

• Offers clear explanations on tricky topics such as electrolytes, fluid balance and acid-base handling
• Features new sections on glomerular filtration, and a new chapter on the global differences in kidney problems
• Includes cross-referencing between basic science and related clinical content
• Focuses on clinical disorders and investigations – ideal for those embarking on medicine rotations
• Illustrates each topic in a double page spread, complete with charts, graphs, and photographs
• An updated companion website is available at www.ataglanceseries.com/renalsystem featuring animations and MCQs

This new edition is the perfect guide for medical students, junior doctors, and allied health professionals, including specialist nurses, who wish to learn, or refresh their knowledge, on the kidney and renal system in health and disease.

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Library of Congress Cataloging-in-Publication Data

Names: O'Callaghan, C. A., author.Title: The renal system at a glance / C. A. O'Callaghan.Other titles: At a glance series (Oxford, England)Description: 4th edition. | Chichester, West Sussex: John Wiley      & Sons, Ltd., 2017. | Series: At a glance series | Includes index.Identifiers: LCCN 2016011606 (print) | LCCN 2016012471 (ebook) | ISBN      9781118393871 (pbk.) | ISBN 9781118393857 (pdf) | ISBN 9781118393864 (epub)Subjects: | MESH: Kidney–physiology | Kidney–physiopathology | Kidney DiseasesClassification: LCC RC902 (print) | LCC RC902 (ebook) | NLM WJ 301 | DDC      616.6/1—dc23LC record available at https://lccn.loc.gov/2016011606

A catalogue record for this book is available from the British Library.

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Cover image: ©gettyimages/SCIEPRO

CONTENTS

Preface to the fourth edition

Introduction and how to use this book

Abbreviations

Glossary

Nomenclature

Normal values

About the companion website

Part 1 Introduction

1 The kidney: structural overview

2 The kidney: functional overview

3 Development of the renal system

4 Clinical features of kidney disease

5 The kidney: laboratory investigations and diagnostic imaging

Part 2 Filtration and blood flow

6 Renal vascular biology

7 Glomerular filtration

8 Renal vascular disease

9 Erythropoietin and anemia in renal disease

Part 3 Sodium and water

10 Renal sodium handling

11 The kidney and water handling

12 Regulation of body sodium and body water

13 Disorders of sodium and water metabolism

14 Hyponatremia and hypernatremia

15 The edema states: sodium and water retention

Part 4 Potassium

16 Renal potassium handling

17 Regulation of potassium metabolism

18 Hypokalemia and hyperkalemia

Part 5 Acid-base

19 Renal acid-base and buffer concepts

20 Renal acid-base handling

21 Acid-base regulation and responses to acid-base disturbances

22 Clinical disorders of acid-base metabolism and metabolic acidosis

23 Metabolic alkalosis, respiratory acidosis, and respiratory alkalosis

24 Renal tubular acidosis

Part 6 Divalent ions – calcium, phosphate and magnesium

25 Calcium, phosphate, and magnesium metabolism

26 Regulation of divalent ions and disorders of phosphate and magnesium

27 Hypocalcemia and hypercalcemia

Part 7 Drugs and genetic disorders

28 Drug and organic molecule handling by the kidney

29 Renal pharmacology: diuretics

30 Hereditary disorders of tubular transport

31 Polycystic kidney disease

Part 8 Glomerular and tubulointerstitial disease

32 Glomerular disease: an overview

33 Glomerular pathologies and their associated diseases

34 Specific diseases affecting the glomeruli

35 Proteinuria and the nephrotic syndrome

36 Tubulointerstitial disease

Part 9 Systemic conditions and the renal system

37 Hypertension: causes and clinical evaluation

38 Hypertension: complications and therapy

39 Pregnancy and the renal system

40 Diabetes mellitus and the kidney

Part 10 Acute kidney injury and chronic kidney disease

41 Acute kidney injury: pathophysiology

42 Acute kidney injury: clinical aspects

43 Chronic kidney disease and kidney function in the elderly

44 Severe chronic kidney disease and renal bone disease

45 Severe chronic kidney disease: clinical complications and their management

46 Treatment of kidney failure with dialysis

47 Peritoneal dialysis and continuous hemofiltration

48 Renal transplantation

49 Global kidney medicine

Part 11 Stones, infection and cancer

50 Urinary tract infection

51 Urinary tract stones

52 Urinary tract cancer

Case studies and questions

Answers

Index

EULA

Guide

Cover

Contents

Preface

Pages

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Preface to the fourth edition

The aim of the first edition of this book (The Kidney at a Glance) was to provide a concise and up-to-date account of the renal system in health and disease. Since that edition in 2000, there have been many exciting new developments in our understanding of the kidney, renal and urinary system, and diseases affecting them, and this edition has been completely revised to incorporate these developments. The content has also been reorganized to integrate the basic science and clinical material in a way that should be useful for all curricula, including problem-based learning. Chapters are grouped in sections that provide an integrated account of each topic from basic science to clinical disorders.

New developments include the role of new ion channels, transporters, and associated molecules, such as barttin, the role of glomerular slit pore proteins such as nephrin and podocin in proteinuria, the function of the polycystin complex in polycystic kidney diseases, the role of WNK kinases in hyperkalemic hypertension, FGF23 in renal phosphate excretion, and the role of flow-activated BK potassium channels in the kidney. In addition, new drugs and therapies are available such as direct renin inhibitors, calcimimetics, phosphate-binding resins, and new approaches to immunosuppression. The latest guidance and approaches to acute kidney injury, chronic kidney disease, and renal replacement therapy have been incorporated where appropriate. There are also new chapters on glomerular filtration and on global kidney medicine. The nomenclature and abbreviations for ion channels, genes, molecules, diseases, and other terms have been completely updated throughout.

This book aims to synthesize all this new information and make sense of it. The book is principally aimed at students, but as with previous editions, it should also be useful to doctors, nurses, or other healthcare professionals who wish to learn about or update themselves on the kidney and renal system in health and disease. This approach has proved very popular, and the book has been circulated worldwide and has been translated into various languages including Chinese, Japanese, Russian, Indonesian, and Greek. Feedback from many readers of the previous editions has guided the writing of this edition and I am grateful to all those who have written to me with their comments. I am grateful to Professor Ian Roberts, Dr. John Scoble, and Dr. Anil Chalisey for permission to use their images in Chapters 7, 51, and 31, respectively. I am also especially grateful for the support and advice of Professor Barry Brenner of Harvard University who coauthored the first edition with me and to many other fine colleagues who have taught me about the renal system over the years.

Chris O'Callaghan

Preface to the first edition

The last few years have seen huge advances in our understanding of how the kidney works and how abnormalities of renal function can affect the whole body. These developments have often resulted from the application of molecular biology, which has led to the cloning of the major transport molecules, channels, and receptors in the kidney, and from careful physiologic studies of the function of these molecules in health and disease. These advances in basic science have transformed the field into one that is highly rational and understandable at all levels from molecular studies of the transporter proteins to clinical studies of patients. As an example, although drugs such as loop diuretics have been prescribed for many years, we now know the precise transporter molecules, which they inhibit, and we can now teach, study, and understand their actions on patients in a completely rational manner. Unfortunately, much of this new information has remained in specialist journals in a piecemeal fashion that makes it difficult for students or physicians to access or put into context.

Our intention is to bring this science in a clear manner to all who need to understand it. We believe that all medical students, doctors, and other health-care providers need to understand the kidney, which is the site of action of so many commonly prescribed drugs and plays a key role in the pathophysiology of so many common disorders, including congestive heart failure and hypertension. We have written this book to draw all this new information together and integrate it with the traditional concepts of renal function and disease. We hope that this new approach, which integrates all the relevant disciplines, including molecular biology, physiology, and clinical medicine, will be of use to all hose work involves the actions of the kidney. We believe that this applies to all students of medicine and all physicians. We also hope that this book will provide the information necessary for others, such as nurses, or nonclinical scientists to rapidly familiarize themselves with the parts of the subject which they need to know.

We have particularly emphasized an understanding of the normal mechanisms and the pathophysiology of the renal system. Although new drugs and treatments may be developed, they must act on the same systems and the same diseases, so knowledge of basic renal function and pathophysiology will stand the reader in good stead for many years to come. This is an exciting field and to do it justice, we have set up a companion website, which will provide a range of supplementary information, including selfassessment material and keypoint summaries. Do please visit the site at www.ataglanceseries.com/renalsystem.

We are very grateful to our publishers for their enthusiasm and support; without them, this work would not have been possible. Lastly, we would like to thank our families for their support and all those who have kindly commented on the manuscript, especially Dr. C.G. Winearls, Dr. J.D. Firth, and Dr. R.M. Hilton. Their advice has been extremely helpful, and any deficiencies that remain are entirely our own.

Chris O'CallaghanBarry M. Brenner

Introduction and how to use this book

This book provides a comprehensive course in the major aspects of renal and urinary system science and disease, which is suitable for students of medicine and other life sciences. It should also be a valuable learning and revision tool for those in more advanced training and a handy reference book for more experienced clinicians. In particular, the incorporation of the very latest molecular renal physiology makes this book ideal for those familiar with traditional renal science to update themselves with this new information. Other healthcare workers, especially nurses and pharmacists, may find the book helpful too.

Although most doctors are not renal physicians, the kidney is involved in many conditions. Almost all doctors prescribe drugs that act on the kidney, such as diuretics, on a regular basis, and are involved in assessing and adjusting fluid and electrolyte balance. It is now recognized that around 5–10% of the population have chronic kidney disease. For this reason, a clear understanding of renal science is essential for all who care for patients, and this book should provide the basis for such an understanding. As well as detailing specific renal diseases, there is full coverage of the major fluid and electrolyte disturbances.

A strong emphasis has been placed on explaining the mechanisms of disease because, unlike drugs or even clinical investigations, the mechanisms of a disease will be the same throughout a clinician's career. A good understanding of renal and electrolyte abnormalities will last a professional lifetime.

Renal science has undergone dramatic transformations over recent years, especially with the molecular understanding of the major transporters and ion channels, and this makes the whole subject much easier to understand. We now know the precise molecular mechanisms of action of key drugs, such as furosemide and the other diuretics, and it is now possible to give a clear explanation of their precise actions in a way that was not previously possible.

The individual chapters are arranged so that the essential material is encapsulated in the pictures, and in general, it will not be necessary to try to memorize material that is not in the pictures. The text provides an explanation of the subject to accompany the pictures. Reading a rational explanation of the subject matter should make it easy to understand the material and subsequently to use the pictures as quick revision aids. Generally, if a subject is not understood properly, it is very difficult to learn, and the text should help learning by providing a rational explanation of all that is presented. Some readers find it helpful to add their own annotations to the pictures when studying or revising.

Several topics have been included for completeness and for more advanced readers, such as those training in internal medicine, pediatrics, and nephrology, or those aiming for particularly high marks in their examinations. A good example would be renal tubular acidosis. Recommended international nonproprietary names (rINNs) have been used for drugs throughout the text, but older commonly used names are also given.

Diagrams

The diagrams of ion movement are all drawn in the same style. In each case, the yellow left side of the image and, therefore, of the cell, is the tubular lumen, and the blue right side of the image and, therefore, of the cell, is the renal interstitium which leads on to the blood. The Na+/K+ ATPase is always shown in yellow. In addition, other transporter molecules are drawn as pink circles if they mediate active transport or as blue circles if they mediate passive transport. Ion channels are shown as two straight lines (see Chapter 2).

Glossary

Active transport A transport process requiring energy in the form of ATP.

Aldosterone A steroid produced by the adrenal cortex promoting sodium reabsorption in the collecting ducts.

Angiotensin II A protein that is a potent vasoconstrictor; it acts via aldosterone and directly on the nephron to promote salt retention.

Antidiuretic hormone (ADH or vasopressin) See Vasopressin.

Antiport The same as counter-transport.

Anuria The complete absence of urine.

Apoptosis Programmed cell death.

Atrial natriuretic peptide (ANP) A peptide produced by cardiac cells causing enhanced sodium excretion.

Bence Jones protein (BJP) Antibody light chains produced by B-cell dysplasias such as myeloma, which are present in the urine and may cause renal disease.

Bowman’s capsule The tubular epithelial component of the glomerulus, which envelops the glomerular capillaries to form a space, Bowman’s space, into which the filtrate passes.

Calyces Divisions of the renal pelvis. The major calyces split into minor calyces and the renal papillae project into the minor calyces.

Carbonic anhydrase An enzyme catalyzing the reaction of carbon dioxide and water.

Casts Cylindrical aggregates of cells or protein debris formed in the distal tubules or collecting ducts.

Cloaca The primitive excretory region in the fetus shared by both the urinary and gut drainage systems.

Collagen A key protein in connective tissue.

Complement A series of proteins triggered by infection or inflammation which promote tissue inflammation and destruction. C4 is a component of the alternative complement cascade. C3 is a component of the common complement cascade, lowered by both classic and alternative complement activation.

Cortex The outer renal tissue containing the glomeruli and most of the proximal and distal tubules.

Co-transport Transport of two molecules or ions in the same direction.

Counter-transport Transport of two molecules or ions in opposite directions.

Creatine kinase An enzyme released from damaged muscle.

Creatinine A metabolic product of creatine metabolism filtered and secreted by the kidney.

Cytokines Soluble molecules that can alter cellular behavior and attributes, particularly during inflammatory processes.

Doppler studies Clinical studies that measure flow in vessels by the Doppler effect on ultrasound waves.

Efficacy The effectiveness of treatment.

End-stage renal disease A loss of renal function so severe that life cannot be maintained without renal replacement therapy.

Erythropoietin A protein produced in the kidney that promotes red blood cell formation.

Filtration fraction This is the ratio GFR/RPF and is a measure of the proportion of plasma passing through the glomerular capillaries that is filtered.

Fundoscopy Looking at the retina, usually with an ophthalmoscope.

Glomerulonephritis Disease of the glomeruli, usually with inflammation.

Hematocrit The proportion of the blood that is made up of red blood cells.

Hematuria Blood in the urine. Frank hematuria means visible blood in the urine.

Homeostasis The maintenance of normal body conditions.

Hydrostatic pressure The physical pressure of water---equivalent to hydraulic pressure.

Immunostaining, immunoperoxidase, immunofluorescence Histological methods using synthetically labeled antibodies to detect the presence of proteins or natural antibodies in tissue specimens.

Interstitial cells Renal cells that support the matrix of the kidney but are not part of the nephron.

Interstitium Connective tissue; in the kidney, the tissue that is not composed of vessels, nephrons, ducts, or other specialized components.

Inulin A substance freely filtered but neither reabsorbed nor secreted, which can be used to estimate glomerular filtration rate.

Iso-osmotic A process that occurs without causing a change in osmolality. Iso-osmotic reabsorption of sodium from the filtrate means that the sodium brings water with it, so that there is no overall change in the osmolality of the filtrate.

Juxtaglomerular apparatus (JGA) The combination of the tubular cells of the macula densa, granular afferent arteriolar cells that secrete renin, and extraglomerular mesangial cells.

Lateral Away from the midline. Medial is toward the midline.

Macula densa A patch of columnar tubular epithelial cells that forms part of the JGA and may sense tubular ion concentration. It is situated at the junction of the thick ascending limb of the loop of Henle and the early distal tubule.

Medial Toward the midline. Lateral is away from the midline.

Medulla The inner kidney constituting the renal pyramids and containing the loops of Henle, the medullary and papillary collecting ducts, and the vasa recta.

Mesangial cells Renal cells in the glomerulus that support the glomerular capillary walls and may have some contractile function.

Mesonephric duct The duct that forms the ejaculatory duct in men.

Mesonephros The second fetal kidney.

Metanephros The final fetal kidney which forms the adult kidney.

Myoglobin A muscle protein with oxygen-binding capacity, which is toxic to renal tubules.

Myoglobinuria Myoglobin in urine.

Nephrin A major filtration slit pore protein.

Nephritic syndrome Acute glomerulonephritis with hypertension, renal impairment, and often edema.

Nephrocalcinosis The diffuse deposition of calcium in the renal tissue.

Nephrolithiasis The formation of renal stones.

Nephron The basic excretory unit consisting of the glomerulus and its tubules.

Nephrotic syndrome Proteinuria sufficient to cause a low serum albumin and peripheral edema.

Oncotic pressure Colloid osmotic pressure.

Ontogeny The pathway of cell differentiation.

Osmolality The concentration of solutes in a given weight of water.

Osmosis The movement of water through a semipermeable membrane from a solution of low osmotic strength (low concentration) to one of high osmotic strength (high concentration).

Ostial lesion Lesion at the opening of a vessel.

PAHp-Aminohippurate: a substance completely cleared by a single pass through the kidney, which can be used to estimate renal blood flow.

Papillary ducts Ducts into which collecting ducts drain and which open out at the tip of the renal papilla into a minor calyx.

Paracellular Around the side of cells.

Paramesonephric duct The duct that forms the female reproductive tract.

Paraprotein A protein that is present at high concentrations and is usually an antibody produced by a B-cell dysplasia, such as myeloma.

Parathyroid hormone A protein produced by the parathyroid gland; it acts on the kidney to promote phosphate excretion, calcium reabsorption, and vitamin D production, and it promotes calcium and phosphate release from bone.

Paresthesia Tingling numbness in the extremities.

Passive transport A transport process that does not require energy.

Podocalyxin A negatively charged glycoprotein that covers the pores in the glomerular capillary endothelial cells and forms part of the glomerular basement membrane.

Podocin A filtration slit pore protein.

Podocytes The thin tubular epithelial cells which form part of the glomerular filtration barrier and cover the urinary aspect of the glomerular capillaries.

Polycythemia Excess red blood cells in the blood.

Polydipsia Excess water intake.

Polyuria Excess urine volume.

Pontine myelinolysis Destruction of neural tissue in the pons when there is rapid correction of disordered osmolality.

Pronephros The earliest fetal kidney which is nonfunctional.

Renal hilus The medial aspect of the kidney containing the entrance sites of the renal artery and vein and the renal pelvis.

Renal pelvis The upper portion of the ureter leading into the calyces.

Renal replacement therapy Treatment that takes over the function of the kidneys, usually dialysis, hemofiltration, or transplantation.

Renin An enzyme released by the JGA, which results in the formation of angiotensin II.

Reticulocyte A nucleated red blood cell precursor.

Rhabdomyolysis Muscle damage or destruction causing the release of nephrotoxic myoglobin.

Slit diaphragm The tight junctions between adjacent podocytes which form part of the glomerular filtration barrier.

Tamm–Horsfall protein Encoded by the UMOD gene. A protein secreted by tubular cells, especially in the thick ascending limb of the loop of Henle. It helps to hold together casts which can form in the tubules.

Transepithelial gradient An electrical or concentration gradient across the tubular epithelium.

Urea A waste product of protein catabolism made by the liver and filtered and reabsorbed by the kidney.

Uricosuric Causing uric acid excretion in the urine.

Uroplakin Protein lining urinary epithelium, which forms a barrier between the cell and urine.

Vasa recta Paired descending and ascending blood vessels, which travel from the cortex to the medulla and back into the cortex with the loops of Henle.

Vasculitis A disease process causing vessel inflammation and damage.

Vasopressin A polypeptide released by the posterior pituitary gland causing water reabsorption in the collecting duct.

Vesical Relating to the bladder, e.g., ureterovesical.

Vitamin D A steroid hormone metabolized in the kidney to the active form 1,25-dihydroxycholecalciferol, which promotes calcium and phosphate absorption from the gut as a principal action.

Wolffian duct The same as the mesonephric duct.

Nomenclature

USA and UK differences in spelling and nomenclature

The main differences relate to the use of “ae” in the UK and “e” in the USA.

USA

UK

anemia

anaemia

diarrhea

diarrhoea

edema

oedema

fetal

foetal

hematocrit

haematocrit

hemoglobin

haemoglobin

hypercalcemia

hypercalcaemia

hyperkalemia

hyperkalaemia

hypernatremia

hypernatraemia

hyponatremia

hyponatraemia

paresthesia

paraesthesia

polycythemia

polycythaemia

In the USA, conventional units such as mg/dL are used, whereas in Europe and most other countries, the SI (Système International) units such as mmol/L are used. For creatinine, to convert from mmol/L to mg/dL, divide by 88.4.

A number of terms differ, in particular:

USA

UK

cyclo porine

ciclosporin

epinephrine

adrenaline (although in the UK epinephrine is increasingly used)

furosemide

frusemide

vasopressin

antidiuretic hormone (ADH)

Normal values

Table 1 Blood biochemistry

Basic electrolytes

Sodium

135–145 mmol/L

135–145 mEq/L

Potassium

3.5–5.0 mmol/L

3.5–5.0 mEq/L

Urea

2.5–8.0 mmol/L

BUN 7–22 mg/dL

Creatinine

60–130 μmol/L

0.7–1.5 mg/dL

Chloride

90–105 mmol/L

90–105 mEq/L

Bicarbonate (venous)

22–28 mmol/L

22–28 mEq/L

Anion gap (Na

+

+ K

+

)− (HCO

3

−

+ Cl

−

)

12–16 mmol/L

12–16 mEq/L

Plasma osmolality

275–295 mmol/kg

275–295 mOsm/kg

Bone

Total protein

60–80 g/L

6.0–8.0 g/dL

Albumin

35–50 g/L

3.5–5.0 g/dL

Calcium

2.15–2.55 mmol/L

8.6–10.2 mg/dL

Ionized calcium

1.0–1.25 mmol/L

4.0–5.0 mg/dL

Phosphate

0.8–1.5 mmol/L

2.5–4.6 mg/dL

Magnesium

0.8–1.2 mmol/L

1.8–3.0 mg/dL

Calcium phosphate product

3.5–4.2 mmol

2

/L

2

43–52 mg

2

/dL

2

Others

Acid phosphatase

50–115 U/L

Amylase

25–180 U/L

Bilirubin

3–17 μmol/L

0.2–1.0 mg/dL

Alkaline phosphatase

80–250 U/L

Alanine aminotransferase (ALT)

5–40 U/L

Aspartate aminotransferase (AST)

15–40 U/L

Gamma-glutamyltransferase (GGT)

10–50 U/L (males)

7–30 U/L (females)

Creatinine kinase

30–250 U/L (males)

30–180 U/L (females)

Prostate specific antigen (PSA)

<4.0 μg/L

Urate

120–420 μmol/L

2.0–7.0 mg/dL

Glucose and lipids

Glucose (random)

3.5–7.8 mmol/L

63–140 mg/dL

Glucose (fasting)

3.5–6.0 mmol/L

63–108 mg/dL

Glycated hemoglobin (glycated HBA1C)

<48 mmol/mol

<6.5%

Cholesterol

3.3–7.3 mmol/L

130–280 mg/dL

Ideally

<5.2 mmol/L

<200 mg/dL

HDL cholesterol

0.9–2.0 mmol/L

35–75 mg/dL

Ideally

>1.2 mmol/L

>46 mg/dL

LDL cholesterol

1.5–4.4 mmol/L

38–170 mg/dL

Ideally

<3.4 mmol/L

130 mg/dL

Triglycerides (fasting)

0.6–1.9 mmol/L

53–170 mg/dL

Immunological

C-reactive protein (CRP)

<10 mg/L

<1 mg/dL

Complement C3

0.7–1.7 g/L

70–170 mg/dL

Complement C4

0.15–0.5 g/L

15–50 mg/dL

IgA

0.8–4.0 g/L

80–400 mg/dL

IgG

6–16 g/L

600–1600 mg/dL

IgM

0.5–2.0 g/L

50–200 mg/dL

IgE

<12–240 μg/L

<41 U/L

Table 2 Urine biochemistry

Sodium

100–300 mmol/24 h

100–300 mEq/24 h

Calcium

2.5–7.5 mmol/24 h

10–30 mg/24 h

Protein

<0.1 g/24 h

<100 mg/24 h

Creatinine

10–18 mmol/24 h

1.1–2.0 mg/24 h

Creatinine clearance

80–140 mL/min

Urine osmolality

60–1200 mmol/kg

500–1200 mOsm/kg

Proteinuria

Approximate equivalent values. ACR—albumin : creatinine ratio, PCR—protein : creatinine ratio. ACR of ≥30 mg/mmol is significant proteinuria. ACR > 2.5 mg/mmol in men or >3.5 mg/mmol in women is significant in diabetic patients

ACR mg/mmol

PCR mg/mmol

24 h proteinuria g/24 h

PCR mg/mg or g/g

30

50

0.5

6

70

100

1.0

12

Table 3 Hematology

Hemoglobin

130–170 g/L (males)

120–160 g/L (females)

White cell count (WBC)

4.0–11.0 × 10

9

/L

4.0–11.0 × 10

3

/mm

3

Platelets

150–400 × 10

9

/L

150–400 × 10

3

/mm

3

Erythrocyte sedimentation rate (ESR)

1–10 mm/h (<50 years)

<20 mm/h (>50 years)

Plasma viscosity

1.1–1.35 mPa·s

Prothrombin time (PT)

12–16 s

International normalized ratio (INR)

1.0–1.3

Activated partial thromboplastin time (APTT)

21–33 s

Ferritin

6–110 μg/L (females)

6–110 ng/mL

20–260 μg/L (males)

20–260 ng/mL

Vitamin B

12

150–700 ng/L

150–700 ng/mL

Red cell folate

100–600 μg/L

100–600 ng/mL

Table 4 Arterial blood gases

PaO

2

10.6–14.5 kPa

80–110 mm Hg

PaCO

2

4.0–6.0 kPa

30–45 mm Hg

pH

7.35–7.45

H

+

35–45 nmol/L

Bicarbonate (arterial)

19–24 mmol/L

19–24 mEq/L

Table 5 Chronic kidney disease and eGFR (see Chapter 43, page 104)

Stage

eGFR (mL/min/1.73 m

2

)

G1

≥90 + kidney abnormality

G2

60–89 + kidney abnormality

G3a

45–59

G3b

30–44

G4

15–29

G5

<15

The urine albumin:creatinine ratio in mg/mmol provides the “A” staging (A1 if < 3, A2 if 3–30 and A3 if >30 mg/mmol).

About the companion website

Part 1Introduction

Chapters

1 The kidney: structural overview

2 The kidney: functional overview

3 Development of the renal system

4 Clinical features of kidney disease

5 The kidney: laboratory investigations and diagnostic imaging

Don’t forget to visit the companion website for this book www.ataglanceseries.com/renalsystem

1 The kidney: structural overview

Gross anatomy

The kidney

The kidneys lie behind the peritoneum at the back of the abdominal cavity, extending from the twelfth thoracic vertebra (T12) to the third lumbar vertebra (L3). The right kidney is lower than the left because of the presence of the liver. During inspiration, both kidneys are pushed down as the diaphragm contracts. Each kidney is covered by a fibrous capsule. This is further surrounded by perinephric fat and then by the perinephric (perirenal) fascia, which also enclose the adrenal gland. The renal cortex is the outer zone of the kidney and the renal medulla is the inner zone made up of the renal pyramids. The cortex contains all the glomeruli, and the medulla contains the loops of Henle, the vasa recta, and the final portions of the collecting ducts.

Vessels and nerves

Blood vessels and the ureter connect with the kidney at the renal hilus. The renal artery arises from the aorta and usually divides into three branches. Two pass in front of the ureter and one goes behind it. Five or six small veins come together to form the renal vein, which leaves the kidney in front of the anterior branch of the renal artery and enters the inferior vena cava. The position of the lymphatics and the renal sympathetic nerves is variable. The lymphatics drain to the lateral aortic lymph nodes. Sympathetic nerves supply the renal vasculature and juxtaglomerular apparatus, and to a lesser extent the rest of the nephron. Afferent fibers enter the spinal cord at T10, T11, and T12.

The draining system for urine

Within the kidney, the pelvis of the ureter divides into two or three major calyces, each of which subdivides into two or three minor calyces. Each minor calyx contains a renal papilla, which is the apex of a medullary pyramid. The ureter passes out of the kidney behind the peritoneum on the psoas muscle and then enters the pelvis in front of the sacroiliac joint. It moves down the lateral pelvic wall toward the ischial spine and then turns forward and medially to enter the bladder. It passes through the bladder wall for 2 cm before opening into the bladder. Urine passes along the ureter by peristalsis. The ureter has three constrictions where kidney stones can become lodged (see Chapter 51). Afferent nerves from the ureter enter the spinal cord at T11, T12, L1, and L2. The bladder is innervated by S3, S4, and S5.

Microanatomy

The nephron

The nephron is the basic unit of the kidney. Each kidney has 400,000–800,000 nephrons, although this number falls with age. A nephron consists of the glomerulus and the associated tubule that leads to the collecting duct. Urine is formed by filtration in the glomerulus; it is then modified in the tubules by the reabsorption and secretion of substances. Cortical nephrons occur throughout the renal cortex and have short loops of Henle; juxtamedullary nephrons begin near the corticomedullary junction and have long loops of Henle, which descend deep into the medulla and enable them to concentrate urine effectively. Cortical nephrons outnumber juxtamedullary nephrons by 7 : 1.

Interstitial cells in the kidney