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Samenvatting Nier fysiologie
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Samenvatting nier fysiologie slides prof. Vennekens
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INHOUDHoofdstuk 1: organisatie van het urinair systeem .............................................................................................. 5
Inleiding ........................................................................................................................................................ 5
Chemische samenstelling .......................................................................................................................... 6
Transport vloeistof tussen compartimenten: interstitium – plasma............................................................ 6
Transport vloeistof tussen compartimenten: intracellulair – extracellulair.................................................. 6
Veranderingen in ICF en ECF ................................................................................................................. 7
Functionele anatomie van de nier ................................................................................................................. 7
Nefron ...................................................................................................................................................... 8
Lichaampje van Malpighi ........................................................................................................................... 8
Juxtaglomerulair apparaat .................................................................................................................... 9
Filtratiebarrière .................................................................................................................................... 9
Nierfunctie.................................................................................................................................................... 9
Regulatie nierfunctie ............................................................................................................................... 10
Feedback via juxtaglomerulair apparaat ............................................................................................. 10
Autonoom zenuwstelsel ..................................................................................................................... 10
Endocrien apparaat ............................................................................................................................ 10
Nierfunctie meten ....................................................................................................................................... 11
Beeldvorming .......................................................................................................................................... 11
Renale klaring ......................................................................................................................................... 11
Glomerulaire filtratierate (GFR) ............................................................................................................... 11
Blaas en urethra .......................................................................................................................................... 11
Innervatie ............................................................................................................................................... 12
Hoofdstuk 2: glomerulaire filtratie en renale doorbloeding ............................................................................. 13
Glomerulaire filtratie................................................................................................................................... 13
Glomerulaire filtratie rate (GFR) .............................................................................................................. 13
Creatinine-klaring ............................................................................................................................... 13
Inuline................................................................................................................................................ 14
Para-aminohippuurzuur ..................................................................................................................... 14
Glomerulaire filtratie obv lading en grootte ........................................................................................ 14
Glomerulaire filtratie door Starling krachten....................................................................................... 14
Vergelijking capillairen ....................................................................................................................... 15
Renale bloed/plasma flow ........................................................................................................................... 15
Controle op RPF en GFR .............................................................................................................................. 16
Autoregulatie .......................................................................................................................................... 16
Gevoeligheid van autoregulatie .......................................................................................................... 17
Samenvattende factoren ......................................................................................................................... 17
1
, Effect van bloedverlies ............................................................................................................................ 18
Hoofdstuk 3: transport van NaCl en water ....................................................................................................... 19
Transport van Na en Cl door nefron............................................................................................................. 19
Na, Cl en watertransport op cellulair niveau ................................................................................................ 19
Na-reabsorptie ........................................................................................................................................ 19
Proximale segmenten ......................................................................................................................... 19
Distale segmenten.............................................................................................................................. 20
Cl-transport............................................................................................................................................. 21
Proximale segmenten ......................................................................................................................... 21
Distale segmenten.............................................................................................................................. 22
Watertransport ....................................................................................................................................... 23
Proximale segmenten ......................................................................................................................... 23
Distale segmenten.............................................................................................................................. 23
Regulatie NA- en Cl-transport...................................................................................................................... 23
Glomerulotubulaire balans ...................................................................................................................... 23
Peritubulaire factoren ........................................................................................................................ 23
Luminale factoren .............................................................................................................................. 24
Renine-angiotensine-aldosterone-systeem (RAAS)................................................................................... 24
Angiotensine II ................................................................................................................................... 25
Aldosterone ....................................................................................................................................... 25
Invloed op NA-reabsorptie ...................................................................................................................... 25
Hoofdstuk 4: transport van ureum, glucose, fosfaat, Ca, Mg en enkele andere organische stoffen ................... 27
Ureum ........................................................................................................................................................ 27
Glucose ....................................................................................................................................................... 27
Andere organische stoffen .......................................................................................................................... 27
AZ-transport in nefron............................................................................................................................. 27
Proteïnentransport in nefron................................................................................................................... 28
Carboxylaat-transport in nefron .............................................................................................................. 28
Organische anionen-transport ................................................................................................................. 28
Organische kationen-transport ............................................................................................................... 29
Zwakke zuren en basen ........................................................................................................................... 29
Urinezuur.................................................................................................................................................... 30
Fosfaat........................................................................................................................................................ 30
Calcium ....................................................................................................................................................... 31
Magnesium ................................................................................................................................................. 32
Hoofdstuk 5: transport van K .......................................................................................................................... 33
K-balans en renale omgang met K ............................................................................................................... 33
2
, K-opname in cellen oiv hormonen ........................................................................................................... 33
Zuur-base afwijkingen ........................................................................................................................ 34
K-handling in nefron ................................................................................................................................ 34
Medullary trapping K .......................................................................................................................... 35
Cellulaire transportmechanismen................................................................................................................ 35
Regulatie K-transport .................................................................................................................................. 36
Plasma K ................................................................................................................................................. 37
Aldosteron .............................................................................................................................................. 37
Arginine vasopressine (ADH) ................................................................................................................... 38
Hoge tubulaire flow ................................................................................................................................. 38
Acidose – alkalose ................................................................................................................................... 38
Integratie van additieve en afzwakkende effecten ................................................................................... 39
Hoofdstuk 6: urineconcentratie en verdunning ............................................................................................... 40
Waterbalans ............................................................................................................................................... 40
Watertransport in nefron ............................................................................................................................ 40
Hyperosmotische medulla en concentratie van urine .................................................................................. 41
Ureum transport in nefron ...................................................................................................................... 41
Ureumaccumulatie draagt bij aan de hyperosmotische medulla ......................................................... 42
Lus van Henle als tegenstroom-principe .................................................................................................. 42
Vasa recta als tegenstroomprincipe ......................................................................................................... 42
Factoren die urinaire concentratiecapaciteit beïnvloeden ........................................................................ 43
Regulatie door AVP/ADH ............................................................................................................................. 43
Cellulair niveau........................................................................................................................................ 43
Hoofdstuk 7: transport van zuren en basen ..................................................................................................... 45
Zuur-base balans......................................................................................................................................... 45
Verzuring ................................................................................................................................................ 45
Urine wordt gebufferd............................................................................................................................. 46
Zuur-base transport in nefron ..................................................................................................................... 46
Algemene mechanismen ......................................................................................................................... 46
Cellulaire mechanismen .......................................................................................................................... 47
H-transport ........................................................................................................................................ 47
Koolzuuranhydrase.................................................................................................................................. 48
HCO3-transport ....................................................................................................................................... 48
Regulatie van renale H-secretie ............................................................................................................... 49
Koppeling tussen H-secretie en Na-transport ...................................................................................... 50
Transport van zuren en basen ..................................................................................................................... 51
Synthese NH3 .......................................................................................................................................... 51
3
, Flux via nier en lever........................................................................................................................... 51
Renale respons op zuur-base afwijkingen .................................................................................................... 52
Intracellulaire en extracellulaire buffers................................................................................................... 52
Respiratoire compensatie ........................................................................................................................ 52
Renale compensatie: aanpassing RNAE .................................................................................................... 52
Eenvoudige zuur-base afwijkingen ........................................................................................................... 53
Analyse .............................................................................................................................................. 53
Hoofdstuk 8: integratie van zout- en waterbalans ........................................................................................... 54
Inleiding ...................................................................................................................................................... 54
Sterk verbonden controlesystemen ......................................................................................................... 54
Regulatie Na-excretie of waterexcretie .................................................................................................... 54
Controle van de extracellulaire osmolaliteit................................................................................................. 55
Regulatie osmolaliteit van bloed en weefselvocht .................................................................................... 55
Synthese en vrijzetting AVP ..................................................................................................................... 55
Osmosensoren ................................................................................................................................... 56
Niet-osmotische triggers voor AVP-release ......................................................................................... 56
Koppeling tussen osmoregulatie en volumeregulatie .......................................................................... 57
Controle van het extracellulair volume ........................................................................................................ 57
Regulatie effectief circulerend volume (ECV) en bloeddruk ...................................................................... 58
Intrinsieke mechanismen reguleren diurese ............................................................................................ 58
Extrinsieke mechanismen reguleren diurese ............................................................................................ 58
RAAS ....................................................................................................................................................... 59
Volumecontractie.................................................................................................................................... 60
Volume-expansie..................................................................................................................................... 60
4
, NIER: FYSIOLOGIE
HOOFDSTUK 1: ORGANISATIE VAN HET URINAIR SYSTEEM
INLEIDING
H2O: tussen 50-60% van ons lichaamsgewicht
Compartimenten
- Extracellulair volume (ECV) (40%)
o Plasma (< proteïnen)
o Interstitieel volume (ISV): niet-bloedcellen (< geen proteïnen)
o Transcellulair vocht
- Intracellulair volume (60%)
Oncotische druk = osmotische druk tgv verschil in hoeveelheid in eiwitten
- Tussen bloedplasma en interstitieel volume
- Bepalen bloeddruk
- Fysiologisch belangrijk
Osmotische druk = drijvende kracht voor watertransport tgv verschil in aantal opgeloste deeltjes
- Wet van ’t Hoff: π = σ (nCRT)
o σ = osmotische coëfficiënt (reflectiecoëfficiënt)
▪ 0: ineffectieve osmoliet
• Deeltje dat vrij doorheen plasmamembraan beweegt, bv ureum
▪ 1: effectieve osmoliet
• Deeltje waarvoor membraantransport gelimiteerd is → °gradiënt, bv
sucrose
o n = aantal deeltjes per molecule
o C = totale concentratie
o R = algemene gasconstante (8,31)
o T = temperatuur (K)
- Tussen interstitieel volume en intracellulair volume
Soortelijk gewicht = totale gewicht van een oplossing in verhouding met gedestilleerd water
Molariteit = aantal opgeloste deeltjes per liter
Molaliteit = aantal opgeloste deeltjes per kg
Toniciteit = effect op celvolume
- Isotoon
- Hypotoon
- Hypertoon
5
,CHEMISCHE SAMENSTELLING
Opgeloste stof Plasma Plasma (geen eiw) Interstitium Cel
Na 142 153 145 15
K 4,4 4,7 4,5 120
Ca 1,2 (ion) 1,3 (ion) 1,2 (ion) 0,0001 (ion)
2,4 (totaal)
Mg 0,6 (ion) 0,6 (ion) 0,55 (ion) 1 (ion)
0,9 (totaal) 18 (totaal)
Cl 102 110 116 20
HCO3 22 24 25 16
H2PO4 en HPO4 0,7 (ion) 0,75 (ion) 0,8 (ion) 0,7 (vrij)
1,4 (totaal)
Proteïnen 7 g/dl / 1 g/dl 30 g/dl
1 mmol/l
Glucose 5,5 5,9 5,9 Laag
pH 7,4 7,4 7,4 7,2
Osmolaliteit 291 290 290 290
TRANSPORT VLOEISTOF TUSSEN COMPAR TIMENTEN: INTERSTITIUM – PLASMA
Formule Starling krachten: Kf = [(Pc – Pi) – σ (πc – πi)]
- K = filtratiesnelheid
- Pc – Pi = hydrostatisch drukverschil
- πc – πi = oncotisch drukverschil
- σ = reflectiecoëfficiënt
Hydrostatische druk
- Arteriële druk
- Veneuze druk
- Precapillaire weerstand
- Postcapillaire weerstand
- Vloeistof duwen uit capillair
Oncotische druk
- Aanwezigheid proteïnen (groter in bloed dan interstitium)
- Vloeistof vanuit interstitium aangetrokken naar capillair
TRANSPORT VLOEISTOF TUSSEN COMPARTIMENTEN: INTRACELLULAIR – EXTRACELLULAIR
Osmotische druk
- Bepaalt verplaatsing van vloeistof over celmembraan
- Verandering osmolaliteit wordt gecompenseerd door verplaatsing van vloeistof (via AQP)
- ICF en ECF in osmotisch evenwicht (door verplaatsing water, niet ionen)
- Meten plasma osmolaliteit → info over ECF en ICF – osmolaliteit
6
, VERANDERINGEN IN ICF EN ECF
Darrow-Yannet diagram:
- Isotoon infuus → toevoegen ECF
o Voor: verhoogd volume ECF
o Compensatie: geen waterflux, want isotoon
o Na: verhoogd volume ECF
- Hypertoon infuus → toevoegen ECF
o Voor: verhoogd volume ECF + hyperosmolariteit ECF
o Compensatie: waterflux van intra naar extra
o Na: verlaagd volume ICF + verhoogd volume ECF + iso-osmotisch
- Hypotoon infuus → toevoegen ECF
o Voor: verhoogd volume ECF + hypo-osmolariteit ECF
o Compensatie: waterflux van extra naar intra
o Na: verhoogd volume ICF + verlaagd volume ECF + iso-osmotisch
Ziekten
- Secretory diarrhea (isotoon) → verlies ECF
o Voor: verlaagd volume ECF
o Compensatie: geen waterflux, want isotoon
o Na: verlaagd volume ECF
- Diabetes insipidius (hypertoon) → verlies ECF
o Voor: verlaagd volume ECF + hyperosmolariteit ECF
o Compensatie: waterflux van intra naar extra
o Na: verlaagd volume ICF + verhoogd volume ECF + iso-osmotisch
- Adrenocorticaal insufficiëntie (hypotoon) → verlies ECF
o Voor: verlaagd volume ECF + hypo-osmolariteit ECF
o Compensatie: waterflux van extra naar intra
o Na: verhoogd volume ICF + verlaagd volume ECF + iso-osmotisch
FUNCTIONELE ANATOMIE VAN DE NIER
Opbouw
- Kapsel
- Cortex – medulla (andere samenstelling)
- Tubuli < epitheelcellen → transportfunctie
- Capillairen < bloed
o Afferent
o Efferent
- Glomeruli: capillairen omgeven door tubuli
o Corticale nefronen: tubuli en bloedvaten oppervlakkig in nierweefsel → peritubulaire
capillairen
o Juxtamedullaire nefronen: tubuli en bloedvaten dieper in nierweefsel → vasa recta
Polycistische nierziekte
- Nieren groeien tot grootte van rugbybal (<-> vuist)
- Niercellen isoleren uit urine voor onderzoek, want sommige snellen ontsnappen uit epitheel van nier
7
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