Renal: Spring Term: lectures: Learning Outcomes – Year 1 (2014) Spring Term



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Giles Kisby GE Y1 Renal

Renal:

Spring Term:

LECTURES:
Learning Outcomes – Year 1 (2014) Spring Term:
Exam questions will be set in standard SBA (single best answer) and EMQ (extended matching

question) formats. The SBA and EMQ formats will be well known to you, and further details are

provided on Blackboard.
LECTURES

Lecture 1: Kidney structure and histology

Lecture 2: Approaches to assessing kidney function

Lecture 3: Renal blood flow and regulation

Lecture 4: Renin Angiotensin system

Lecture 5: Water loading states

Lecture 6: The lone Englishman lost in the Sahara

Lecture 7: Acid base balance – physiology

Lecture 8: Acid base balance – illustrations from the

critically ill patient’s physiology

Lecture 9: Renal causes of hypertension

Lecture 10: Erythropoetin

Lecture 11: Sodium and potassium handling

Lecture 12: Clinical scenarios (electrolytes)

Lecture 13: When the kidneys are lost

Lecture 14: Clinical demonstration: video and meeting with

a renal patient

Lecture 15: Renal physiology scenarios

Lecture 16: Overview of kidney function and dysfunction

Lecture 17: Predict the consequences of loss of endocrine

functions of the kidney

Lecture 18: Control of calcium and phosphate; vitamin D, PTH

and the kidney

The main goal of this course is to help you develop a sound understanding of how the renal

system achieves the vital functions of controlling fluid and electrolyte balance, its role in control of

blood pressure and as part of the endocrine system - and how these functions are perturbed in

disease. The course has been designed to develop and present core material from a clinical

perspective. The primary goal is to equip you with the knowledge base to apply basic renal

science to clinical practice in the later years of your course, recognizing that the practice of renal

medicine, and fluid and biochemical management in all patients, is integrally related to the

physiological processes you will cover over this term. We also hope to instill a finer appreciation

of the scientific intricacies of the renal system.

The course is structured in three overlapping themes: Theme one covers functional anatomy and

histology. In the second theme, the essentials of fluid and electrolyte balance are understood

through lectures on physiology and illustrations from clinical pathology. Theme three explores the

consequences to normal physiology ‘when things go wrong’ in disease states.

At the end of the course, you will be able to:

1) Describe the structural organisation of the kidneys and urinary tract at the system and

cellular levels.

2) Explain the physiological mechanisms by which the various components of the kidney

produce and regulate the composition of urine.

a) Define Renal Clearance and Glomerular Filtration Rate and explain in principle how

these may be measured in patients

3) Understand the principal renal mechanisms responsible for homeostasis of water,

electrolytes, pH, glucose and urea in the extracellular fluid.

a) Appreciate the centrality of water in the control of cell volume, blood pressure and

metabolism

b) Understand the physiological implications of dehydration and how the body responds to

it

c) Understand the physiological implications of water loading states and how the body



responds to them

d) Understand the intracellular and extracellular balance of sodium and potassium ions

including how and why the gradients are maintained.

e) Understand why maintenance of appropriate pH is important physiologically

4) Understand how renal mechanisms contribute to the control of blood pressure.

5) Describe the sites and mechanism of action of the main classes of diuretics.

6) Use the knowledge of kidney function and roles to:

a) Understand how the body responds to overload and deficiencies of sodium and

potassium, including the pathological features found in each situation.

b) Determine the implications of sodium and potassium abnormalities in a number of

different clinical scenarios.

c) Identify several clinical scenarios in which acid-base balance is disrupted.

d) Describe how the body deals with acid-base abnormalities in a number of different

situations. - 2 -

7) Outline the principal causes of acute and chronic renal failure.

a) Show awareness of the clinical features people may develop in acute and renal failure.

b) Outline the possible ways of managing these patients.

c) Show awareness of the different modalities of renal replacement therapy.

LECTURES

Lecture 1: Kidney Structure and Histology

Dr Ruth Tarzi, (r.tarzitiimperial.ac.uk)

 To understand the gross anatomy of the kidney

 To be aware of its principal relations to other structures

 To understand the basic structure of the glomerulus at a cellular level

 To appreciate how this structure controls its filtering function

 To know the component parts of the nephron and the basic function of each part

 To understand the sampling and handling issues related to taking a medical renal biopsy

• To understand the purpose of the medical renal biopsy

• To be able to recognise in a renal biopsy some of the possible deviations from the norm

Lecture 2: Approaches to assessing renal function

Dr Peter Hill (peter.hill4tinhs.net)

 To understand the physiological functions of the kidney

 To understand how kidney function can be measured

 To understand methods for measuring or estimating glomerular filtration rate

 To understand how to assess urea and creatinine readings in renal disease states

 To know how to assess proteinuria and haematuria

Lecture 3: Renal blood flow and regulation

Dr Nish Arulkumaran, (n.arulkumarantiimperial.ac.uk)

 To learn about the anatomical and physiological concepts underlying the renal

vasculature and perfusion,

 To provide insights into the intrinsing and extrinsic mechanisms involved in regulation of

renal blood flow

 To gain understanding on pathophysiology of renal vascular impairmen

Lecture 4: Renin-angiotensin system and control of blood pressure

Dr Nish Arulkumaran (n.arulkumarantiimperial.ac.uk)

 To learn about the blood pressure: what it does to/for the body, how do we measure it

 RAS system - components and roles, therapeutic targets

 Pathophysiology of hypertension and renal involvement

Lecture 5: Drinking yourself to death: water loading states

Dr Ruth Tarzi (r.tarzitiimperial.ac.uk)

 Understand the principal mechanisms responsible for the homeostasis of serum sodium,

osmolality and total body water content.

 Understand the functions of antidiuretic hormone.

 Understand the physiological implications of water loading and how the body responds to

it. - 4 -

 Understand the causes and consequences of pathological water loading states e.g.

syndrome of inappropriate ADH secretion, primary polydipsia, secondary

hyperaldosteronism.

Lecture 6: The lone Englishman lost in the Sahara Desert.

Dr Jeremy Levy (j.levytiimperial.ac.uk)

To understand how the body handles water and what can go wrong. To understand how to

interpret blood results in this context and how disorders of water balance might be managed.

Much of the body is water. Water allows solutes to remain dissolved, and changes in body water

can cause changes in solute concentrations. Physiological processes require tight control of

solute concentrations, and hence water distribution is also tightly regulated.

Control of body water is mainly through the kidneys. The proximal tubule reabsorbs 70% of water

filtered together with salt, but cannot change the concentration of urine (iso-osmolar

reabsorption). The loop of Henlé in the kidney allows humans to make dilute urine, while the

distal tubule and collecting ducts act to make concentrated urine, through the action of ADH (or

Vasopressin). Humans can change the concentration of their urine over a very wide range. ADH

is the key hormone controlling water balance, but many others affect water homeostasis via

actions on salt and water (eg cortisol, thyroxine, atrial natriuretic peptide).

Excess water leads to solute dilution (eg hyponatraemia) whilst water deprivation leads to solute

concentration (eg hypernatraemia). Both these states can cause severe problems. Both can also

be caused by bad doctoring, as well as by hormone dysfunction, drugs, behaviour etc.

Dehydration (in its true form loss of water only) leads to increased concentration of solutes, and

reduction of both extracellular and intracellular volume. Dehydration is a very potent stimulus to

ADH release, which should minimise further water loss through the kidneys by increasing the

reabsorption of water in the distal tubules – less water is excreted in the urine. If this does not

happen and water loss is not corrected, dehydration leads to death. Under- or over-activity of the

hormone systems controlling water balance can lead to over or under-hydration, and various

electrolyte disturbances. Excess ADH leads to water retention and hyponatraemia, while too little

ADH leads to diabetes insipidus and dehydration. The rennin-angiotensin system is also crucial

in control of water balance via the effects of angiotensin II and aldosterone on sodium handling

and vasoconstriction.

It is important to identify the cause of disturbance in patients physiology in order that the correct

action can be taken to remedy the situation – if water is missing, water needs replacing alone; if

salt is lost, salt needs replacing.

Lecture 7: Acid-Base balance – physiology

Dr Doris Doberenz (doris.doberenztiimperial.nhs.uk)

 Lecture and relevant articles will be made available on Blackboard

Lecture 8: Acid Base Balance – illustrations from the critically ill patient’s physiology

Dr Doris Doberenz (doris.doberenztiimperial.nhs.uk)

 Cases will be provided on the day of the lectures

- 5 -

Lecture 9: Renal causes of hypertension



Dr Peter Hill (peter.hill4tinhs.net)

 Understand the pathological consequences of uncontrolled hypertension

 Appreciate when to suspect secondary hypertension and know causes of secondary

hypertension

 To be aware of imaging modalities to investigate renovascular hypertension

 To be aware of treatment options for renovascular hypertension

 To be aware of therapeutic approaches to treating primary and secondary hypertension

Lecture 10: Erythropoeitin

Dr Peter Hill (peter.hill4tinhs.net)

 To be aware of the physiological functions of erythropoetin and its regulation

 To understand the consequences of dysregulation of the HIF axis

 To be aware of the therapeutic uses of erythropoetin

 To understand the approach to managing anaemia in renal disease

Lecture 11: Sodium and potassium handling

Dr Elaine Clutterbuck (Elaine.clutterbucktiimperial.nhs.uk)

 To understand the factors affecting sodium and potassium balance.

a) the levels are regulated, and the role of the kidneys

b) that there is a close relationship between – sodium and water homeostasis,

and between potassium and hydrogen ion balance.

 To outline some of the clinical conditions associated with an imbalance of sodium

/ potassium

a) their symptoms, signs and immediate management

Lecture 12: Discussion of clinical scenarios

Dr Damien Ashby (d.ashbytiimperial.ac.uk)

Lecture 13: When the kidneys are lost

Dr Damien Ashby (damien.ashbytiimperial.nhs.uk)

 Understand the pathophysiology and treatment of end stage renal disease

Lecture 14: Clinical demonstration : video and meeting with renal patient

Dr Liz Lightstone (l.lightstonetiimperial.ac.uk)

 Understand how kidney failure impacts on patients’ lives

 Understand the practicalities involved in dialysis and transplantation

Lecture 15: Renal Physiology – clinical scenarios

Dr Jeremy Levy (j.levytiimperial.ac.uk)

 Cases for self-directed learning will be made available on Blackboard

Lecture 16: Overview of kidney function and dysfunction with respect to learning

objectives of the course

Dr Damien Ashby (damien.ashbytiimperial.nhs.uk)

Lecture 17*: Predict the consequences of loss of endocrine functions of the kidney

Professor Karim Meeran (k.meerantiimperial.ac.uk)

- 6 -


Lecture 18*: Control of calcium and phosphate: vitamin D, PTH and the kidney; Professor

Karim Meeran (k.meerantiimperial.ac.uk)

* These two lectures will be given in the Pathology (Part 2) Course where they sit more

appropriately.



LECTURES:
07/01/14: Introduction to the kidney: anatomy and histology: Ruth Tarzi

Los (from booklet):

 To understand the gross anatomy of the kidney

 To be aware of its principal relations to other structures

 To understand the basic structure of the glomerulus at a cellular level

 To appreciate how this structure controls its filtering function

 To know the component parts of the nephron and the basic function of each part

 To understand the sampling and handling issues related to taking a medical renal biopsy

• To understand the purpose of the medical renal biopsy



• To be able to recognise in a renal biopsy some of the possible deviations from the norm

Los (from Slides):

  • To understand the gross anatomy of the kidney

  • To be aware of its principal relations to other structures

  • To understand the basic structure of the glomerulus

  • To appreciate how this structure controls its filtering function

  • To know the component parts of the nephron

  • To understand the role of the renal biopsy in diagnosis of kidney disease


Notes:


  • Basic anatomy:

    • Kidneys are at T11-L2 on left; kidneys are T12-L3 on right

    • Kidneys are 11-13cm long

    • Pathway of urine after kidney:

      • Urine collects in central portion (pelvis)

        • By the time it reaches this point, urine is in its final state

      • Drains into ureters (on on each side)

      • Collects in bladder

      • Excreted by (single) urethra

    • Renal parenchyma = Cortex and medulla

    • Approximately 1 million filtering units; the nephrons





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