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Urinary SyStem - Microscopic a s p e c t- Departemen Anatomi-Histologi FKUB  DAFTAR MASALAH SKDI 2012 Sistem Ginjal dan Saluran Kemih Tidak bisa menahan/ urgensi 1 Nyeri pinggang 4...

Urinary SyStem - Microscopic a s p e c t- Departemen Anatomi-Histologi FKUB  DAFTAR MASALAH SKDI 2012 Sistem Ginjal dan Saluran Kemih Tidak bisa menahan/ urgensi 1 Nyeri pinggang 4 kencing Peningkatan atau penurunan 2 5 Nyeri saat BAK frekuensi buang air kecil (BAK) 3 Berkurangnya jumlah air kencing 6 BAK mengejan 7 BAK tidak puas 13 Air kencing campur udara 8 Akhir kencing menetes 14 Air kencing campur tinja 9 Pancaran kencing menurun 15 Keluar darah dari saluran kencing Darah keluar bersama produk 10 Kencing bercabang 16 ejakulat Waktu kencing preputium 11 17 Air kencing seperti teh melembung Duh (discharge) dari saluran 12 Air kencing merah 18 kencing  Daftar penyakit, SKDI level 3-4 1 Urinary tract infection 4 2 Gonorrhea 4 3 Uncomplicated Pyelonephritis 4 4 Paraphimosis 4 5 Acute glomerulonephritis 3A 6 Chronic glomerulonephritis 3A 7 Renal colic 3A 8 Urinary stone diseases or urinary calculi without colic 3A 9 Phimosis 3A 10 Prostatitis 3A 11 Torsion of testis 3B 12 Ruptur uretra 3B 13 Ruptur kandung kencing 3B 14 Ruptur ginjal 3B 15 Benign prostatic hyperplasia 3A 16 Striktura uretra 3B 17 Priapismus 3B 18 Chancroid 3A  FUNCTION Removes toxic by products of metabolism Regulate blood pressure, hemodinamic and acid base balance Endocrine function, release: – Renin – Erythropoietin (by peritubular cell)  Kidneys. consist of nephrons and Components a system of collecting ducts;  filter blood and produce urine Ureters. Muscular tubes that collect urine output from the kidney and carry it to the urinary bladder Urinary bladder. Hollow muscular organ that stores urine Urethra. Tube that drains urine from urinary bladder to the exterior  Contents:  Kidneys (ren)  excretory passages :  Ureters  Urinary bladder / VU (Vesica urinaria)  Urethrae 8 REN : Cortex-medulla  The renal cortex It consists primarily of renal the superficial layer corpuscles and convoluted tubules. Medullary rays = Medullary tissue located in the cortex = tubules that extend from the base of each renal (medullary) pyramid into the cortex  Three type substances in the cortex – Renal corpuscle – Cortical labyrinth: the convoluted tubulus – Medullary rays: straight portion of proximal and distal tubule, collecting duct  Renal (medullary) pyramids are conical or pyramidal structures whose bases are adjacent to the The renal medulla, cortex the renal medulla. Deep to cortex Each kidney contains 10 to 18 renal pyramids. each pyramid consists primarily of the thin limbs of loops of Henle, blood vessels, and collecting tubules. sends extensions into the cortex = (medullary rays) Renal columns. Extensions of cortical tissue between renal pyramids apex of each renal pyramid. renal papilla  Renal lobulations Renal lobule. Renal lobe Renal lobe. consists of a renal pyramid and its closely associated cortical tissue Renal lobule. A central medullary ray and the adjacent cortical labyrinth extending to the interlobular vessels nephrons drain into the collecting tubules of the medullary ray. interlobular vessels Renal Blood Vessels Arteri Renalis Branch of aorta abdominalis A. renalis bercabang menjadi: – a. suprarenalis inferior – Branches to the perinephric tissue, renal capsule, pelvis and proximal part of the ureter Near the hilum a. renalis divides into divisi anterior and divisi posterior  a. segmentalis  branch into lobar arteries  divide into interlobars  A.arcuata in junction of medulla and cortex Arcuates send interlobular arteries into cortex Cortical radiate arteries give rise to glomerular arterioles 17 19  The Nephron consist of : a renal corpuscle, proximal convoluted tubule (TCP), loop of Henle, distal convoluted tubule (TCD) The structure of nephrons and associated blood vessels The Nephron renal corpuscle, TCP 1. A renal corpuscle consists of loop of Henle, TCD – glomerulus – Bowman capsule, as location of blood filtration – Podocytes – Renal filtration barrier Renal Corpuscle Glomerulus: supplied by afferent arteriole and drain by efferent arteriole Bowman’s capsule: – Visceral layer Bowmann’s space: the space inside – Parietal layer Vascular pole: the region where the vessels enter and exit Bowmann’s capsule Urinary pole: the region of continuation between the renal corpuscle and the proximal tubule renal corpuscle, glomerulus TCP Bowman capsule loop of Henle, Podocytes TCD Renal filtration barrier Glomerulus. A tuft of fenestrated capillaries, formed by an afferent arteriole, leaves the glomerulus via the efferent arteriole. (1) Glomerular endothelial cells (2) The basal lamina (3) The mesangium : Mesangial cells and mesangial matrix  glomerulus renal corpuscle, Bowman capsule TCP Podocytes loop of Henle, Glomerulus. Renal filtration barrier TCD (1) Glomerular endothelial cells : = inner layer of the capillary walls. Have large fenestrae (60–90 nm in diameter) but lack the thin diaphragms (Fenestrated capillaries) (2) The basal lamina is between the podocytes and the glomerular endothelial cells :by both cell populations. Contains three distinct zones: (a) The lamina rara externa, adjacent to the podocyte epithelium (b) The lamina densa, a thicker, intermediate zone, Collagen, type IV (c) The lamina rara interna, adjacent to the capillary endothelium (3) The mesangium : the interstitial tissue between glomerular capillaries. It is composed of mesangial cells and an amorphous extracellular matrix  glomerulus renal corpuscle, Bowman capsule TCP Podocytes loop of Henle, Renal filtration barrier TCD Mesangial cells : phagocytose can contract,  decreasing the surface area available for filtration. possess receptors for angiotensin II and atrial natriuretic peptide. The mesangial matrix helps support glomerular capillaries.  glomerulus renal corpuscle, Bowman capsule, TCP Podocytes loop of Henle, Bowman’s capsule. Renal filtration barrier TCD Double-walled, epithelial capsule with central space called Bowman’s space; surrounds the glomerulus and receives the fluid filtered from the blood – Parietal layer. Outer layer, simple squamous epithelium – Visceral layer; Inner layer surrounding the glomerulus. Consists of a single layer of modified epithelial cells called podocytes. Poles of the glomerulus  Vascular pole. Where afferent and efferent arterioles enter and leave the renal corpuscle,  Urinary pole. Where the parietal layer of Bowman’s capsule is continuous with TCP  Visceral layer of Bowmann’s capsule Epithelial cells of visceral layer are modified to podocytes Podocytes have numerous cytoplasmic extension: primary processes, each have many secondary process, known as pedicel completely envelop the glomerular capillaries by interdigitating with pedicels from neighboring podocytes  Podocytes glomerulus renal corpuscle, Bowman capsule, TCP  Have several primary Podocytes loop of Henle, Renal filtration barrier TCD processes that give rise to many secondary = highly modified epithelial cells that processes called form the visceral layer of the Bowman capsule. pedicels  Pedicels of adjacent podocytes interdigitate and surround the glomerular capillaries. The slits (filtration slits) between the pedicels are bridged by slit diaphragms (a layer of filamentous material)  The openings between the pedicels are called filtration slits Filtration slits are covered by a thin slit diaphragm that extends between neighboring pedicels The slit diaphragm has pores ranging from 4 to 14 nm  glomerulus renal corpuscle, Bowman capsule, TCP Podocytes loop of Henle, Renal filtration barrier The renal filtration barrier TCD – Fenestrated endothelium of glomerular capillary – Thick, fused basal laminae of the podocytes and the glomeru-ar endothelial cells – Slit diaphragms between pedicels of visceral layer of epithelium Histology of a renal corpuscle MEDICAL correlation Inflammation within the glomeruli (=glomerulonephritis). acute or chronic,.e.c humoral immune reactions. the deposition of circulating antibody-antigen complexes within glomeruli or circulating antibodies binding to either glomerular antigens or extraneous antigens deposited in the glomeruli.  elicit a local inflammatory response. Let’s take a look once more and zoom in again Filtration Membrane The renal filtration barrier  Podocyte Filtration Membrane The renal filtration barrier  renal corpuscle, n TCP e p Tubular section loop of Henle, h TCD r o n (processes the filtrate) – Proximal convoluted tubule – Loop of Henle – Distal convoluted tubule (ends by joining collecting duct) Proximal convoluted duct Confined to renal cortex Pyramidal or cuboidal epithelial cells renal corpuscle, with round nuclei and long microvilli TCP at the apical surface (brush border) loop of Henle, TCD Prominent interdigitations along their lateral borders, which interlock adjacent cells with one another Resorption of water, ions and solutes (active transport of Na+ out of the tubule)  renal corpuscle, TCP loop of Henle, TCD thick descending limb of loop of (thick ascending Henle limb of Henle’sloop),  Loop of Henle Descending limb ( pars recta) – Lined by cells that structurally similar to those of the convoluted tubules Thin segment – Lined by squamous simplex ep Thick ascending limb – Lined by cuboidal cells but narrower than proximal segment – No brush border  renal corpuscle, TCP Loop of Henle. loop of Henle, Located in medullary tissue (medullary ray & medulla) TCD Proximal tubule, straight portion. Located either in medullary ray (in cortex) or in medulla. Histology is identical to that of TCP Thin segment, Found in medulla. – Composed of a simple squamous epithelium – Actively pumps out chloride, with sodium following passively, to produce a hypertonic urine Distal tubule, straight portion. Located in medulla or in medullary ray (in cortex) – Composed of a simple cuboidal epithelium with inconsistent microvilli. The basal plasma membrane is extensively infolded with numerous mitochondria between the folds. Distal convoluted tubule Confined to the renal cortex Begins near the vascular pole and terminate and terminate by becoming continuous with arched collecting tubule renal corpuscle, TCP Simple cuboidal epithelium loop of Henle, TCD Macula densa, a specialized group of cells on the side of tubule adjacent to the vascular pole Selective secretion and resorption of ions  renal corpuscle, TCP loop of Henle, Distal convoluted tubule TCD Located in the labyrinth portion of cortex; highly convoluted lacks a brush border, Histology is identical with the distal straight tubule Returns to a glomerulus to form part of the juxtaglomerular apparatus Major site of salt and water control in the body  The JG apparatus is located at the vascular pole of the renal corpuscle. It helps to maintain blood pressure 1. JG cells : primarily in the wall of the afferent arteriole, as modified smooth muscle cells = protein-secreting cells.  synthesize renin and store it in secretory granules. 2. Macula densa cells : tall, narrow, closely packed epithelial cells of the distal tubule. appear as a dense spot (macula densa) 3. Extraglomerular mesangial cells/ = polkissen (pole cushion)/lacis cells. Lie between the afferent and efferent glomerular arterioles.  Regulation of blood pressure JG cell – modified muscle cells secreting renin. Macula densa – chemoreceptors JG apparatus Function. (if there) A decrease in extracellular fluid volume (perhaps detected by the macula densa)  stimulates JG cells to release renin into the bloodstream. Renin acts on angiotensinogen in the plasma, converting it to angiotensin I. In capillaries of the lung and elsewhere, angiotensin I is converted by angiotensin-converting enzyme (ACE) to angiotensin II, a potent vasoconstrictor that stimulates release of aldosterone in the adrenal cortex. Aldosterone stimulates the epithelial cells of the distal convoluted tubule to remove Na+ and Cl  Water follows the ions, thereby increasing the fluid volume in the extracellular compartment, which leads to an increase in blood pressure. MEDICAL correlation There are many different glomerular diseases involving the renal corpuscles, with different causes calling for different treatments. Accurate diagnoses of such disorders by pathologists require sampling of the cortex and may involve examination of the renal corpuscles by immunofluorescence light microscopy or even by TEM  collecting system The connecting tubule is a short segment between TCD and the collecting tubule. It is lined by two types of epithelial cells: a. Principal (light) cells have many infoldings of the basal plasma membrane. These cells remove Na from the filtrate and secrete K into it. b. Intercalated (dark) cells have many apical vesicles and mitochondria. These cells remove K from the filtrate and secrete H into it. Collecting tubule/TUBULUS COLLECTIVUS Composed of simple cuboidal to simple columnar cells; usually displays distinct lateral boundaries between cells Drains urine from the distal convoluted tubule enters the medullary ray in the cortex and descends into the medulla Joins with other collecting tubules to form the papillary ducts (of Bellini) helps in concentrating the urine 1. Cortical collecting tubules are located primarily within medullary rays, They are lined by a simple epithelium containing two types of cuboidal cells.  Principal (light) cells AND Intercalated (dark) cells 2. Medullary collecting tubules. Similar in structure to cortical collecting tubules 3. Papillary collecting tubules (ducts of Bellini) are large collecting tubules (200–300 μm in diameter), formed from converging smaller tubules. They are lined by a simple columnar cells that have a single central cilium. They empty at the area cribrosa, a region at the apex of each renal pyramid that has 10 to 25 openings  into a minor calyx. Connecting tubule  Collecting duct Each receives urine from several nephrons Run straight through cortex into the deep medulla At papilla of pyramid, ducts join to form larger papillary ducts The papillary ducts open on the area cribrosa of the papilla into minor calices The linining cells range in height from cuboidal in the initial to tall columnar in the papillary ducts.  1 2 3 Collecting duct minor calyx excretory passages & Ureters renal passageways Apex of each renal pyramid renal papilla  It has a perforated tip (area cribrosa) that projects into the lumen of a minor calyx. It is continuous with the major renal calyces, Then into renal pelvis is a funnel-shaped expansion of the upper end of the ureter. Extrarenal passageways (intra) renal passageways Minor and major calyces. Transport urine to the renal pelvis and into the ureter; lined by transitional epithelium Renal pelvis. formed by the union of major calyces. Histologically similar with ureter  Extra renal passageways Ureter. Muscular tube connecting the renal pelvis and the urinary bladder, lined by transitional epithelium; two layers of smooth muscle in the upper two-thirds, inner longitudinal and outer circular, (with the addition of a third outer longitudinal layer in the 1/3 distal). Outer fibrous: loose c.t URETER H&E 1: IL 2: OC MUCOSA LAMINA PROPRIA MUSCULARIS ADV MEDICAL correlation renal calculi (kidney stones) : – obstruction that can lead to renal problems, – movement of stones from the renal pelvis into the ureter can cause extreme pain on the affected side of the body. – Tx : lithotripsy Bacterial infections of the urinary tract can lead to inflammation of the renal pelvis and calyces, or pyelonephritis. – In acute pyelonephritis bacteria often move from one or more minor calyx into the associated renal papilla, causing accumulation of neutrophils in the collecting ducts. VESICA URINARIA  provide for distension of the organ; Mucosa: – Transitional epithelium – Lamina propria Superficial: Dense irregular c.t, Deeper : Loose c.t Muscular: – Inner longitudinaal – Middle circular – Outer longitudinal Adventitia: – Dense irregular c.t  BLADDER transitional epithelium MEDICAL correlation Cystitis, or inflammation of the bladder mucosa, Such inflammation is common during urinary tract infections, can also be caused by immunodeficiency, urinary catheterization, radiation, or chemotherapy. Chronic cystitis can cause an unstable urothelium, with benign urothelial changes involving hyperplasia or metaplasia. Bladder cancer is usually some form of transitional cell carcinoma  Urethra – The urethra conveys urine from the bladder outside the body. In males, the urethra also carries semen during ejaculation. – It has a two-layer muscularis consisting of an inner longitudinal and an outer circular layer of smooth muscle. – It is surrounded at some point by an external sphincter of skeletal muscle, which pemits its voluntary closure.  The Urethra The Male Urethra ► Extends from neck of urinary bladder ► To tip of penis (18–20 cm) ► 20 cm long and is divided into prostatic, membranous, and cavernous portions. ► contains mucus-secreting glands of Littre in the lamina propria.  Male urethra – 20 cm long and is divided into prostatic, membranous theurogenital diaphragm, and cavernous portions penile urethra [spongy urethra] – It is lined by transitional epithelium in the prostatic portion and by pseudostratified or stratified columnar epithelium in the other two portions. – The fossa navicularis, located at the distal end of the cavernous urethra, is lined by stratified squamous epithelium. – contains mucus-secreting glands of Littre in the lamina propria.  The Female Urethra Is very short (3–5 cm) Extends from bladder to vestibule External urethral orifice (ostium urethrae externum) is near anterior wall of vagina Epithel: transitional  stratified-squamous (although patches of pseudostratified columnar epithelium are present) It may contain glands of Littre in the lamina propria.  The External Urethral Sphincter (M. sphincter urethrae externa) In both sexes: – is a circular band of skeletal muscle – where urethra passes through urogenital diaphragm Acts as a valve Is under voluntary control: – via perineal branch of pudendal nerve Has resting muscle tone Voluntarily relaxation permits micturition  RESUME Dalghi MG, Montalbetti N, Carattino MD, Apodaca G. The Urothelium: Life in a Liquid Environment. Physiol Rev. 2020 Oct 1;100(4):1621-1705. doi: 10.1152/physrev.00041.2019. Epub 2020 Mar 19. PMID: 32191559; PMCID: PMC7717127. UROTHELIUM MEDICAL correlation Urinary tract infections, usually involving coliform bacteria or Chlamydia, often produce urethritis and in women often lead to cystitis because of the short urethra. Such infections are usually accompanied by a persistent or more frequent urge to urinate, and urethritis may produce pain or difficulty during urination (dysuria).  Terminologi Hematuria peritoneal dialysis Polyuria continuous Dysuria ambulatory peritoneal dialysis Urolithiasis Hemodialysis Nephrolithiasis (Nephrotoxic) acute Kolik tubular necrosis Retensio urine Diabetes insipidus Cystoscopy RESUME RESUME RESUME  Suggested homework - Struktur yang terganggu - Patofisiologi SKDI - Gejala - Target Penatalaksnaan  Suggested homework Region Epithelium Major Functions Summary etc  Suggested reading Basic Histology, Juncquiera Human Anatomy Martini PRINCIPLES OF ANATOMY AND PHYSIOLOGY Tortora Essential Pathophysiology , Porth Color Textbook of Histology, Leslie P. Gartner Bailey’s Textbook of Microscopic Anatomy, Selamat belajar….