changes of renal functions in the elderly
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Manifestation of Novel Social Challenges of the European Union in the Teaching Material of Medical Biotechnology Master’s Programmes at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011. - PowerPoint PPT PresentationTRANSCRIPT
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Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011
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CHANGES OF RENAL FUNCTIONSIN THE ELDERLY
Miklós Székely and Erika PéterváriMolecular and Clinical Basics of Gerontology – Lecture 11
Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011
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With aging:• Renal mass decreases• Renal blood flow (RBF) decreases• Number of functioning nephrons decreases• GFR decreases, glomerular dysfunctions• Tubular dysfunctions• Excretory capacity decreases• Role in salt/water regulation decreases• Role in pH regulation decreases• Non-excretory renal functions decrease
AGING vs. RENAL FUNCTIONS
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Macula densa
Red blood cells
Podocyte (visceral layer)
Mesangial cell
Basement membrane
Parietal layer ofBowman’s capsule
Afferent arterioleEfferent arteriole
Distal renal tubule
Glomerular structures
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Glomerular structures
Red bloodcell
Podocytes(visceral layer)
Mesangial cell
Basement membrane
Capillary
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Glomerular structures:filter surface
Podocyte(epithelial cell
with foot processes)
Mesangialcell
Red blood cell
Endothelialcell
Capillary lumen
Foot processes
Basement membrane
Red blood cell
Capillary lumen
Bowman’s space
Fenestrations
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filtration of polyanions accumulation of circulating
aggregates in mesangiumfusion of podocyte
foot processes
proteinuria mesangial matrixproduction and
proliferation
focal sclerosis
Anionic charge of glomerular capillaries
Development ofglomerulosclerosis 1
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Glomerular sclerosis
Glomerular sclerosis
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Chronic loss ofrenal tissueProtein intake Diabetes mellitus
hyperglycemia
Hypertrophy and vasodila-tion in remaining nephrons
Glomerular pressure
Altered permselectivity
Arterial pressure
Glomerular hyperfiltration
Direct cellular injury
Cell proliferation and platelet aggregation
Mesangial matrix overproduction
Glomerular sclerosis
Increased protein filtration
Compensatory polyuria
Albuminuria Mesangial cell damage
Development ofglomerulosclerosis 2
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TÁMOP-4.1.2-08/1/A-2009-0011Pe
rcen
t of t
otal
nep
hron
s
SNGFR (nl/min)
0
10
20
30
0 0 10 20 30 40 50 60 70 80
(37.5)
GFR100%
0
10
20
30
0 0 10 20 30 40 50 60 70 80
(20)
GFR~50%
0
10
20
30
0 0 10 20 30 40 50 60 70 80
(37.5)
40
GFR100%
Aging influences single-nephron-GFR (SNGFR)
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GFR
(ml/m
in)
Years
40
20
60
80
100
120
140
30 40 50 60 70 80
Age vs. GFR
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• In th elderly GFR, tendency for azotemia due to a fall of kidney perfusion (thirst, heat, CO redistribution e.g. heart failure), but no proportional rise in se-creatinine (less muscle lost)
• Tubular reabsorption changes: glucose reabsorbing tubular cells still function, minerals: tendency for K-loss, salt wasting (Na-reabsorption), phosphaturia, poor ADH action (water loss).
• Proteinuria more frequent.• Excretory capacity (drugs!) decreases.• Severe shifts in the osmotic pressure.
Age vs. nephron dysfunctions
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ADH effect decreases with age U/
P in
ulin
(urin
e/pl
asm
a co
nc.
ratio
)
Urine Collection Period0
0
102030405060708090
100110120
1 2 3 4 5 6 7 8 9 10
YoungMiddleOld
ADH
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80
300
400
600
1,000
1,500
Osmoticpressure
Proximal tubuleDistal tubule
Corticomedullary osmotic concentration gradient
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No ADH16 ml
1500
1200
900
600
300
0
Osm
olal
ity (m
Osm
/kg)
100 ml
20 ml
20 ml
2.0 ml
0.3 ml
Lot of ADH
Prox. tub. Loop of Henle Dist. tub +Cort.
collecting duct
Medullary collecting
duct
Concentrating and diluting the urine
NormalHyposthenuria
20 ml
Fluid volume along the nephron
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Spec
ific
grav
ity o
f urin
e
Number of nephrons
1,0002,000,000 1,500,000 1,000,000 500,000 0
1,010
1,020
1,030
1,040
Hyposthenuria
Development of hyposthenuria
Isosthenuria
Specific gravity of plasma
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• Impaired excretion of substances that are excreted through the kidneys the dose of drugs that are eliminated through the kidney has to be decreased!
• Kidney perfusion decreases frequently for a number of reasons, e.g. redistribution in heart failures, exsiccosis – impaired excretory functions – drug doses have to be adjusted.
Kidney and drugs
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• Atrophy of renal parenchyma + sclerotic a. renalis regulation of blood pressure defective, tendency for hypertension, but hypovolemia may cause hypotension.
• Erythropoietin deficiency due to reduced renal parenchyma and gonadal hormon secretion anemia.
• Active D-vitamin formation decreases bone abnormalities (senile osteoporosis).
Aging vs. non-excretory kidney functions
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TÁMOP-4.1.2-08/1/A-2009-0011Most common renal diseases and genitourinary conditions in the elderly• Diabetic nephropathy• Glomerulonephritis• Pyelonephritis• Interstitial
nephropathy - analgesic nephropathy- uric acid nephropathy- myeloma kidney
• Urinary retention(The muscles of the bladder and pelvic floor weaken.)
• Urinary incontinence(The capacity of the urinary bladder reduces which leads to frequent urination.)
• Urinary infections • Benign prostatic
hyperplasia, prostate cancer
• Atrophic vaginitis
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Renal failure in the elderly:causesThe incidence of acute renal failure increases following acute tubular necrosis.Risk factors: • age-related decrease
of RBF, GFR, and of ability to concentrate or to dilute urine,
• diabetes mellitus, • hepatic cirrhosis,• congestive heart
failure,
• drugsChronic ischemic renal disease and progressive damage of the renal parenchyma lead to chronic renal failure.Risk factors:• diabetes mellitus• hypertension• hyperlipidemia• obesity
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TÁMOP-4.1.2-08/1/A-2009-0011Renal failure in the elderly:dialysis and kidney transplantationThe most common indication of dialysis due to chronic renal failure is diabetic nephropathy (35-40%). There is an increase in the number of renovascular diseases. Among the dialyzed there are less candidates for transplantation due to co-morbidity. The overall survival increases due to the improved efficacy of dialysis. With higher capacity of dialysis, the age-related limits of dialysis have faded away.Age is not a contraindication of kidney transplantation. Both the cadaveric and the living donor can be an option in the elderly. The only limiting factor for kidney transplantation is the presence of multimorbidity (hypertension, DM, significant atherosclerosis).
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Urinary tract infection
Symptoms: fever, dysuria (pain upon urination), urgency, frequency, incontinence, impaired physical and/or mental status. Sepsis can develop quickly and atypically — treatment of urosepsis is extremely difficult. Pathogens: E. Coli, Enterococci, Streptococci, Proteus.Treatment: oral rehydration, frequent urination, selected antibiotics, roboration.
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Incontinence
Definition: Involuntary loss of urine through the urethra.Types: • functional, • stress, • urge, reflex, • overflow.
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Functional incontinence
The patient is not able to control his bladder due to altered circumstances. Causes: • disability, • impaired vision, • dementia, • bigger amount of urine (i.e. diuretics, diabetes
mellitus)Management: • changes in the environment, • timed voiding (scheduled bathroom visits), • urinary indwelling catheter as required,• diapers.
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Stress incontinence Involuntary loss of urine upon elevated intra-abdominal pressure.Causes:• urethral sphincter insufficiency due to weakness of
pelvic floor musculature,• obesity,• prolapsed uterus, atrophic vaginitis, bladder hernia.Management:• weight loss,• Kegel exercises, electro-stimulation,• estrogen, medication (Ditropan, Melipramin), • surgery,• panty liners.
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Urge/reflex incontinence Sudden, unexpected urge to void after certain
stimuli.Causes:• atrophic vaginitis, cystitis,• benign prostatic hyperplasia (BPH),• certain drugs or foods, cold.Management:• casual treatment,• avoiding coffee/tea/alcohol,• estrogen, medication (Ditropan),• electro-stimulation, behavioral training (biofeedback).
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Overflow incontinence Unexpected urine loss from the overfilled
bladder.Causes:• benign prostatic hyperplasia (BPH),• fibrotic stenosis of the urethra,• muscles of the bladder and pelvic floor weak.Management:• casual treatment,• avoiding coffee/tea/alcohol,• estrogen, medication (Ditropan),• behavioral training (biofeedback).