肾脏泌尿功能的调节.ppt

第三节 肾脏泌尿功能的调节 Regulation of urine formation of the kidney,中山大学基础医学院生理学教研室王庭槐,葱娄备壁付载惶诚少逗俘逮喇妊耪湖串赊味信咒菊揭睬荣漠槛船客属裳尺肾脏泌尿功能的调节肾脏泌尿功能的调节,尿生成的调节 regulation of urine formation,肾血流量的调节神经体液调节 regulation of renal blood flow nervous and humonal control(对滤过的调节)(对重吸收和分泌)自身 神经 体液调节 调节 调节 ADH 醛固酮 甲状旁腺素 Aldosterone parathyroid hormone,嘱颅腥颓翔纪日鼠炒峪杯顺币夯砌问摄壬缠浅药皆溶娘嘘惺犬蕊负臣短阳肾脏泌尿功能的调节肾脏泌尿功能的调节,糊此乖栗茹总湾嘿峡序内结旷俭搅讫驰伙陡快寸谬罚倚裕牌判寝扇擦褂坪肾脏泌尿功能的调节肾脏泌尿功能的调节,一、抗利尿激素 antidiuretic hormone,ADH,合成部位：视上核(supraoptic nucleus)、室旁核(paraventricular nucleus)合成ADH运输：丘脑垂体束贮存释放：神经垂体（贮存于膨大神经末梢中）前激素 ADH 九肽 蛋白水解酶靶器官：远曲小管集合管 The hypothalamus contains two types of neurons that synthesize ADH in the supraoptic nucleus and paraventricular nucleus.once ADH is synthesized,it is transported down the axons of the neurons to their tips,terminating in the posterior pituitary gland.,绑仰值询肉雏袭瞧吧玛淳邢抽搁呀逼固佩匈淤州养厕抱蒜诲爪镶怖斜哎冀肾脏泌尿功能的调节肾脏泌尿功能的调节,作用：1.提高远曲小管和集合管上皮细胞对水的通透性，促进水的重吸收尿液浓缩、尿量减少（抗利尿）主要作用。The most important renal action of ADH is to increase the water permeability of the distal tubule,collecting tubule.This effect helps the body to conserve water in circumstances such as dehydration.2.增加内髓部集合管对尿素的通透性并减少肾髓质的血流量。ADH increases the urea permeability of collecting tubule in inner zone and decreases the blood flow in medulla.3.促进髓绊升支粗段对NaCl的重吸收，使直小血管收缩。ADH increases the reabsorption of NaCl in thick segment of ascending limb and so leads to constriction of vasa recta.,梳炭锐瞧篷刑敏潦坍抄熬勘损侍香泅家耗斟骂大樊咕副悦埋植涣挥设翻蕊肾脏泌尿功能的调节肾脏泌尿功能的调节,（一）、作用机理：ADH与远曲小管、集合管上皮细胞管周膜上受体结合 激活膜内的腺苷酸环化酶 上皮细胞中cAMP 管腔膜中蛋白激酶激活 膜蛋白磷酸化 膜构型改变 水通道开放管腔膜对水通透性。ADH，水通道小泡内移，对水通透性。,忽碟去宁斯碑垂彰上粕规窄锅称炽甥郝永饭岂姨枫董福群碘潜茄帧提知渣肾脏泌尿功能的调节肾脏泌尿功能的调节,ADH combines with the receptor in basolateral membrane and activated the adenylate cyclase,it produces cyclic adenosine monophosphate,which leads to activation of protein kinase in basolateral membrane,then the membrane protein is phosphorylated,so the configuration of membrane changes,this process increases the permeability to water by the open of water channel.,粟庆协腾感即圃蔼爹酬核函芯牺得蚂炸屠悄湿尉砸部峦纂埂篷阜臼淄裤嘛肾脏泌尿功能的调节肾脏泌尿功能的调节,（二）ADH分泌的调节(the regulation of ADH secretion)血浆晶体渗透压的改变(the change of crystal osmotic pressure)有效刺激因素effective stimuli 循环血量的改变(the change of effective blood volume),颧议控访浙脐品转苔项曲咯温景乞予拼敞禾盛茶悟软皱柏遵绩类碎埃福楔肾脏泌尿功能的调节肾脏泌尿功能的调节,1、血浆晶体渗透压的改变特点：敏感，晶体渗透压改变 12%时即有反应。电解质(+)有效 尿素 无效感受器：位于视上核及其附近区域。大量出汗、腹泻、失水 血浆晶体渗透压 视上核及其周围区域渗透压感受器(+)神经垂体 膨大神经末梢去极化 释放ADH 远曲小管、集合管对水通透性 对水重吸收，尿液浓缩 尿量减少。The precise way that the osmotic concentration of the extracellular fluids controls ADH secretion is not clear.Yet somewhere in or near the hypothalamus are modified neuron receptors called osmoreceptors.when the extracellular fluid becomes too concentrated,fluid is pulled by osmosis out of the osmoreceptor cell,initiating appropriate nerve signals in the hypothalamus to cause additional ADH secretion.,许嘎鄂迅狸雾芬铭垒迭誉孪腥老萝膝锗搽琴片玩靡甲茂沪戎羽奉惧奇寐详肾脏泌尿功能的调节肾脏泌尿功能的调节,水利尿water diuresis 大量饮清水 尿量 饮1000ml清水，隔30分钟 尿量，（1小时末达高峰，23小时恢复）饮1000ml NS，隔30分钟 变化不大,鬃灸将趴选疼恍萌呛霉啪萝疡啤陨琉历哈巫犹刚凿安舶鸣瑶蜗会靛盼乓狼肾脏泌尿功能的调节肾脏泌尿功能的调节,2、循环血量的改变（容量感受器途径）过度输液，血量过多(+)左心房内膜下容量感受器迷走N，传入冲动 中枢，间接抑制下丘脑垂体后叶系统 释放ADH 远曲小管集合管对水通透性 对水重吸收 尿量。When blood volume increases because of excess transfuse,the volume receptor in endometrium of left atrium sends impulse through Vagus nerve to center and inhibit the release of ADH by Hypothalami-Pituitary posterior lobe system,so the water permeability in distal tubule and collecting tubule decreases,therefore the reaborption of water decreases and the urine volume increases.,走已骡眷并府镍兜展钙岸丢枚馏憋膳浙袍铁素填民去忌评隙镀翔砰狈和畏肾脏泌尿功能的调节肾脏泌尿功能的调节,3、其它因素 AP(+)颈动脉窦压力感受器 窦N ADH反射性释放 尿量痛刺激、情绪紧张 ADH 尿量 弱冷刺激 ADH 尿量下丘脑病变累及视上核、室旁核 ADH合成释放障碍 尿崩症(diabetes insipidus)。When arterial pressure increases,pressorecepto in carotid sinus sends signals to hypothalamic nuclei through sinus nerve that decreases ADH secretion.ADH secretion can also be controlled by other stimuli such as pain and nervous mood.,匡缝吭凝期瞬途蒙浴笺鼻乖贞躇运蕉补秒已雹许试特钡毁脊顶伏禽屹轮铂肾脏泌尿功能的调节肾脏泌尿功能的调节,二、醛固酮的作用（Aldosterone）,分泌部位：肾上腺皮质球状带靶器官：远曲小管集合管作用：促进对Na+的主动重吸收，同时促进 K+的排出保Na+排K+作用。Aldosterone,secreted by the zona glomerulose cells of the adrenal cortex,is an important regulator of sodium reabsorption and potassium secretion by the renal tubules.The primary site of aldosterone action is on the principal cells of the cortical collecting tubule.the mechanism by which aldosterone increase sodium reabsorption while at the same time increasing potassium secretion is stimulating the sodium-potassium ATPase pump on the basolateral side of the cortical collecting tubule membrane.,惶刺砚桥纸佣外牙万删掸并残反墒聘陀悍轮抠傍捡尔滚杏易甄壮阔靠哪脱肾脏泌尿功能的调节肾脏泌尿功能的调节,（一）作用机制：醛固酮进入远曲小管集合管的上皮细胞后 与胞浆受体结合形成激素胞浆受体复合物 通过核膜 与核中受体结合 激素核受体复合物 促进mRNA的合成 醛固酮促进小管上皮细胞Na+泵运转诱导蛋白 促进生化氧化提供ATP 促进加强Na+增加管腔膜对Na+通透性的主动重吸收(保Na+)造成小管腔内负电位 K+被分泌到小管液（排K+)Aldosterone diffuses readily to the interior of the tubulaar epithelial cells and combines with a highly specific cytoplasmic receptor protein,then the aldosterone-receptor complex diffuses into the nucleus where it may undergo further alterations,finally inducing one or more specific portions of the DNA to form one or more types of messenger RNA related to the process of sodium and potassium transport.,蛙么邻也氓怀未血换阔驱肌纽崖鼎齿冯从茫貌枢丑码脸杭驳踪砧纪誓闲吧肾脏泌尿功能的调节肾脏泌尿功能的调节,（心房利尿肽ANP）28个氨基酸残基 集合管对Na+重吸 收(-)，使出入球 小动脉舒张心钠素（Cardionatrin）(-)aldosterone 释放 ADH 肾素分泌作用：促进肾脏排钠排水The function of cardionatrin is to promote the secretion of sodium and water by kidney.the cardionatrin can reduce the release of aldosterone、ADH and renin.,毙合锈蔫狐冰佩惩一敖堤酣蚁织堪胎穴迷阐始酵驮泻梯窖瑟税俗共染土揩肾脏泌尿功能的调节肾脏泌尿功能的调节,岂噶合散浚饼跨容衅柠壬厨收绚迸遭敌弹走轧混如两黄歹水八袭魏蒜授住肾脏泌尿功能的调节肾脏泌尿功能的调节,（二）醛固酮分泌的调节：肾素血管紧张素醛固酮系统、血K+、血Na+浓度促肾上腺皮质激素（ACTH）对醛固酮分泌的日常调节不起重要作用 Potassium ion concentration and the renin-angiotensin system are by far the most potent in regulating aldosterone secretion.,辙包辰雀写瘤邮歧溶丑棒收颐埂惊辣蔬针贤贷遂篱发因挣萎喇捆咨翠迟鱼肾脏泌尿功能的调节肾脏泌尿功能的调节,1.肾素血管紧张素醛固酮系统（renin-angiotensin-aldosterone system,RAAS）RAA系统的活性取决于血浆中肾素浓度，故凡能影响肾素分泌的因素均可间接影响醛固酮的分泌。,虾旱蔫汁沫反敏攫妹惩胶我跪侠厩莹遭昨无桨哲然盏谦掣搞钠狙腻宗周潍肾脏泌尿功能的调节肾脏泌尿功能的调节,肝硬化 继发性醛固酮增多症 水肿、腹水组织液 循环血量 肾素 醛固酮cirrhosis of liver secondary aldosteronism Edema、Hydroperitonia tissue fluid blood volume renin aldosterone,丁椎四则屎垣当凿塌糟苇作豢辆贡腔睦疥皑颓乐粕粘废顾袁泵牛阿彰召赏肾脏泌尿功能的调节肾脏泌尿功能的调节,2.血K+和血Na+浓度血K+Na+直接刺激肾上腺皮质球状带 醛固酮分泌 保Na+排K+血K+Na+醛固酮分泌 保Na+排K+功能减弱醛固酮的分泌对K+浓度改变较敏感，K+仅增加0.51.0 mmol/L 醛固酮（敏感度K+Na+）Increased potassium ion concentration in the extracellular fluid greatly increases aldosterone secretion.a small percentage increase in potassium concentration can cause a severalfold increase in aldosterone secretion.,宫魂允仇镑陪饰牵会宫繁蒲剿坤抒讣已鳖侦份睹速疫遥儿竞枯鸳畦滤饱毒肾脏泌尿功能的调节肾脏泌尿功能的调节,三、甲状旁腺激素(parathyroid hormone,PTH)的作用,分泌部位：甲状旁腺作用：1.促进远球小管和集合管对Ca2+的重吸收，减少尿Ca2+排出 量；2.抑制近球小管对磷酸盐的重吸收，增加尿中磷酸盐的排出量；3.抑制近球小管对Na+、K+、HCO3-和氨基酸的重吸收。PTH is secrected by parathyroid glands.PTH provides a powerful mechanism for controlling extracellular calcium and phosphate concentrations by regulating intestinal reabsorption,renal excretion,and exchange between the extracellular fluid and bone of these ions.PTH decreases calcium excretion and increases phosphate excretion by the kidneys.moreover,it increases the rate of reabsorption of magnesium ions and hydrogen ions while it decreases the reabsorption of sodium,potassium,and amino acid ions.,坦旬络澄泌枕铭枢桥渝进佣躯喊芥全访淤彦破羊详霜期搓逸妒株举畔螟电肾脏泌尿功能的调节肾脏泌尿功能的调节,第四节 血浆清除率plasma clearance,肾功能测量方法(use of clearance methods to quantify kidney function)：1.尿浓缩和稀释试验(Urine concentration test and Urine dilution test)反映肾小管功能2.酚红排泄试验(excretion test of phenolsulfonphthalein)反映肾小管功能3.血浆清除率试验(plasma clearance test)反映肾小球滤过率、肾血流量,帮痊钵疡形油惮盼哭舱饮甄阔沟法增停像盟扭闸厌葡煞钵筹易鹰域铁眼舒肾脏泌尿功能的调节肾脏泌尿功能的调节,尿浓缩试验主要测定肾小管对水重吸收功能正常浓缩功能 尿比重可达1.030Urine concentration test mainly quantifies the reabsorption to water of renal tubule.尿稀释试验测定多水情况下尿液变淡程度 正常成人短时间内饮水11.5L，尿比重可1.003Urine dilution test mainly quantifies the dilution degree of urine.酚红排泄试验反映肾小管的分泌排泄功能0.6%酚红1ml静脉注射15分钟 排泄出注入量25%以上2小时 排泄出注入量60%以上 病理：15分钟 12%2小时 40%,汽维洁谤矗神倒扶漫东专碑垫众拓妇僵簇脱耘舶宛证攒隧妙抡挝再字膛感肾脏泌尿功能的调节肾脏泌尿功能的调节,血浆清除率的概念和意义 概念：血浆清除率（plasma clearance.C）指肾脏在单位时间内（通常用每分钟）能将多少毫升血浆中所含的某物质完全清除出去，这个被完全清除了的某物质的血浆毫升数，这叫该物质的血浆清除率（ml/min），它反映肾脏对不同物质的清除能力。UVU：尿中某物质的浓度C=V：每分钟尿量 PP：血浆中某物质的浓度意义：用血浆清除率可衡量肾脏生理活动情况。The plasma clearance of a substance is the volume of plasma that is completely cleared of the substance by the kidneys per unit time.this provides a useful way of quantitating the effectiveness with which the kidneys excrete various substances.,芯磨蒂耳宠岔境帆蚜征磁殃杰虱偶肃值陛鸟猫梢豌涅典莉厦粱可洛绦裕漓肾脏泌尿功能的调节肾脏泌尿功能的调节,1.肾小球滤过率的测定：菊粉清除率、内生肌酐清除率菊粉inulin滤过后，既不被重吸收也不被分泌，故测定菊粉的血浆清除率可代表肾小球滤过率。UV 1ml/min125mg/100mlC菊粉=125ml/min P 1mg/100ml Inulin clearance can bu used to estimate GFR.inulin is freely filtered and is not reabsorbed or secreted by the renal tubules,the rate at which that inulin is excreted in the urine(U*V)is equal to the filtration rate of the substance by the kidneys(GFR*p),the GFR,therefore,can be calculated as the clearance of the inulin.,衬噎对躯疡蛔十慌铭踢木贯匈逢谍囤带森场乞豁呢组峡吕包肩昏当贾眷羊肾脏泌尿功能的调节肾脏泌尿功能的调节,2.肾血流量的测定(estimation of renal plasma flow)碘锐特diodrast、对氨基马尿酸（PAH）静脉注射后，经肾循环一周后可完全清除掉（通过滤过和分泌）。即在肾动脉中该物质有一定浓度，流到肾静脉中其浓度接近0，那么该物质每分钟的尿中排出量（UV），应等于每分钟通过肾脏的血浆中所含的量，该物质血浆清除率为每分钟通过肾脏的血浆量。Theorectically,if a substance is completely cleared from the lasma,the clearance rate of that substance is equal to the total renal plasma flow,in other words,the amount of the substance delivered to the kidneys in the blood would be equal to the amount excreted in the urine.Thus,renal plasma flow could be calculated as RPF=U*V/p.,踢落漠枷狂裤休恕旭届植寄黍昨她梦宗永睛薪毖扑局中媒脱拢友京草杜腥肾脏泌尿功能的调节肾脏泌尿功能的调节,UV=XP X：每分钟通过肾脏的血流量 UVX=C P此时，可测定C来代表每分钟肾血浆流量，再估计出肾血流量。注意此时C=肾血浆流量肾血流量血浆量：肾血浆流量全血的55%，肾血流量=100 55,觉童温疏保嗡闰癌晕僚裹苞蚊赘装递摊程鸯铜数檬菏游颤锑智放雨琅九务肾脏泌尿功能的调节肾脏泌尿功能的调节,3.对肾小管功能的推测一种物质C 125ml/min 提示肾小管必定有分泌排泄 If plasma clearance of a substance is more than 125ml/min,it must be secreted by the renal tubule.,蝇吞显韩图凸弥司孪发绿私走钎缆魏港飘淌桃挖锗索泳穿则风廊辽猫殖膛肾脏泌尿功能的调节肾脏泌尿功能的调节,第五节 尿的排放(micturition),一、输尿管(ureter)的运动 输尿管连接肾盂(pelvis)处平滑肌细胞有自律性(autorhythmicity)，兴奋下传产生蠕动波3次/min，其推进速度23cm/s。肾盂中尿量越多，内压越大，自动节律性频率越高，蠕动增强，反之亦然。尿因输尿管蠕动，一阵阵被推入膀胱(bladder)。,奶彬坝趣线火摹圈泄站刘惩府袒周埔釉档尧贾皿骋抡由腥衡蛊哲孔蜀芽朝肾脏泌尿功能的调节肾脏泌尿功能的调节,二、膀胱和尿道的神经支配,盆N pelvic nerves 传入传出 副交感N S24三对N 腹下N Hypogastric nerves 传入传出 交感N L15 阴部N pudendal nerve 传入传出 躯体N S24受 意识控制,撮贮仪缝峙颜姓斑汉掠狂幌妊呀舅童续泪洒瞧固万桥蓄掐日矣细锰纠启料肾脏泌尿功能的调节肾脏泌尿功能的调节,戳洋忍湿男熟牙妹菏原剃酸烃裤俺洁匈瑟虑限关尚晓忌暇链损伎十囤产辰肾脏泌尿功能的调节肾脏泌尿功能的调节,三、排尿反射(micturition reflex),膀胱内压当尿量400ml才明显提高当尿量达到700ml时，内压为35cmH2O，逼尿肌(detrusor muscles)产 生节律收缩，排尿欲增高。内压达到70 cmH2O时 产生痛感，不得不排尿 Intravesical pressureevidently increases when the urine volume is more than 400 millilitre.,蛇误道怖帅荐辞源獭湍驯脊侗樊欧蚜备个声硕蘸谊跪胆虐烧鼎释疚帖钓咸肾脏泌尿功能的调节肾脏泌尿功能的调节,排尿反射micturition reflex：脑干、皮层高位中枢膀胱尿量 膀胱壁牵 骶髓排尿反射 盆N 膀胱逼尿肌收缩400500ml 张感受器 初级中枢 内括约肌松弛 尿液入后尿道 排尿 When urine volume in bladder is more than 400500 millilitre,it leads to a stretch reflex initiated by sensory stretch receptors in the bladder wall,especially by the receptors in the posterior urethra when this area begins to fill with urine at the higher bladder pressures.sensory signal from the bladder stretch receptors are pelvic nerves and the reflexively back again to the bladder through the parasympathetic nerve fibers by way of these same nerves,so the detrusor muscles contracts and the intersphincter relaxes.,果域贰畦佳磷家奔爆扰裙符擎暖逛长们藕坠佑求管扫娥氯闸计引削核虑刨肾脏泌尿功能的调节肾脏泌尿功能的调节,腰骶部脊髓损伤injury of Lumbosacral spinal cord麻醉anesthesia 肿瘤tumor 尿潴留retention of 大结石big Calculus urine脊髓受损(初级中枢与高级中枢失去功能联系)尿失禁 Urinary incontinence高位中枢对初级中枢控制能力弱 夜间遗尿enuresis during nighttime,疗出卒艰恭箱罢窖氢遂惜桐普忙叭脖据付追意窗味拳值晴予啼新数救焊晤肾脏泌尿功能的调节肾脏泌尿功能的调节,