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Anatomy and Physiology of Ageing 4: the Renal System

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Anatomy and Physiology of Ageing 4: the Renal System Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice Keywords: Ageing/Respiratory system/Respiratory tract infections/ Systems of life This article has been Renal system double-blind peer reviewed In this article... l How age affects the normal functioning of the renal system l Age-related changes to the kidneys, bladder, urethra and prostate l How declining renal function can affect various conditions in older age Anatomy and physiology of ageing 4: the renal system Key points Authors Maria Andrade and John Knight are both senior lecturer in biomedical The renal system science, College of Human Health and Science, Swansea University. 1is the most powerful regulator Abstract The functions of the renal system include removal of waste products; of the body’s regulation of blood volume, blood pressure and red blood cells; and balancing of internal environment electrolytes and blood pH. Renal function starts to gradually decline after the third With advancing decade of life but, in the absence of disease, the renal system is able to fulfil its role 2age, renal blood throughout life. In spite of this, many anatomical and physiological changes mean flow – and therefore older people are prone to issues such as polyuria, nocturia and incontinence. This glomerular filtration fourth article in our series on the anatomy and physiology of ageing explains how age rate – are reduced affects the organs of the renal system, leading to a reduction in renal function. The mass and 3weight of the Citation Andrade M, Knight J (2017) Anatomy and physiology of ageing 3: the renal kidneys decrease system. Nursing Times [online]; 113: 5, 46-49. significantly after the age of 50 years The progressive he renal system is the most pow- to lead, obesity and increased inflamma- 4degradation of erful regulator of the body’s tory mediators in the blood (Weinstein and renal function leads internal environment. Healthy Anderson, 2010). to issues typical of Tkidneys are essential to maintain old age such as homeostasis, ensuring stable conditions Anatomical changes polyuria, nocturia in which all cells can function optimally. Pre-renal changes and incontinence They perform several functions (Montague The most important pre-renal (occurring Most men et al, 2005), including: before the kidney) change affecting kidney 5experience a l Removal of waste products such as function is vascular degeneration. In benign enlargement urea, uric acid, creatinine and toxic young adults, renal blood flow is estimated of the prostate breakdown products of drugs; to be approximately 600ml/minute; in gland as they get l Regulation of blood volume and pressure; older people this is often reduced by half older, but this l Electrolyte (salt) balance; (Cukuranovic and Vlajkovic, 2005) pri- prostatic hyperplasia l Acid-base balance (regulation of marily due to normal age-related changes can also be a sign of blood pH); in blood vessels (see Part 1 of this series) malignancy l Regulation of the number of and is often exacerbated in people with erythrocytes (red blood cells); atherosclerosis of the renal artery. l Synthesis of vitamin D. Such blood vessel changes usually lead In the absence of disease, the kidneys to ischaemia (reduced oxygenation), par- function optimally into the third decade of ticularly in the outer portion of the kidney life, after which there is a gradual decline (renal cortex). Cells gradually die and are in renal function (Figs 1 and 2). Around 15% replaced with scar tissue, giving the outer of people over the age of 70 years have var- surface of aged kidneys a granular or mot- ying degrees of renal disease and dysfunc- tled appearance. The arterioles leading to tion (Coresh et al, 2007). Factors contrib- the glomeruli (filtration membranes) show uting to the decline in renal function deposition of hyaline (clear cartilage- include hypertension, smoking, exposure like material) and collagen below the Nursing Times [online] May 2017 / Vol 113 Issue 5 46 www.nursingtimes.net Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice Systems of life Fig 1. Tubule abnormalities Age-related changes to the renal system Some kidney tubules gradually degenerate and are replaced by scar tissue (tubulo- Increased collagen deposition, reduced interstitial fibrosis). This seems associated renal blood flow and glomerular filtration rate, loss of nephrons and abnormal with an increasing number of cells nephron structure showing features of senescence (Sturm- lechner et al, 2017), which reduces the area available for the reabsorption of useful Increased risk of materials such as glucose, amino acids and urinary incontinence salts. The distal convoluted tubules often due to: shrink and may develop small pouches l Reduced bladder elasticity (distal diverticula), which can in turn l Loss of sphincter become fluid-filled cysts, increasing the tone risk of kidney infection and pyelonephritis l Poor bladder (Zhou et al, 2008). control Impaired renal repair Shortened urethra in some In young adult kidneys, around 1% of renal women may increase risks cells have the ability to divide and prolif- of urinary tract infection. Prostatic erate. This declines with age, reducing the hyperplasia in men may interfere kidneys’ ability to repair. The chemical sig- with urine flow nalling pathways that coordinate cell divi- sion and repair in the kidneys also become impaired with age (Bolignano et al, 2014). endothelium; this reduces the diameter of Renal changes the vessels, thereby restricting blood flow. Both kidney mass and weight decrease sig- Diet and renal ageing The smallest blood vessels in the kidney, nificantly after the age of 50 (Zhou et al, Age-related changes in renal structure and including the capillaries that form the glo- 2008). The kidneys of people in their 20s function are thought to occur as a result of meruli, also progressively degenerate and weigh 250-270g each; in 90-year-olds this has both genetic and environmental factors are replaced with fibrous scar tissue dropped to 180-200g. It has been estimated (Bolignano et al, 2014). One factor that (Musso and Oreopoulos, 2011). that, between the ages of 40 and 80, approxi- appears to play a role is exposure to oxida- Aged blood vessels experience a general mately 20% of kidney mass is lost (Choud- tive stress, which tends to lead to the reduction in the synthesis of the potent hury et al, 2016); only 3% of people in their release of pro-inflammatory mediators. vasodilator nitric oxide (see Part 1 of this 90s have histologically normal kidney tissue. While most oxidative stress is linked to series) and this contributes to reducing There is a gradual increase in collagen free radicals produced during cellular blood flow to the kidneys (Weinstein and deposition, leading to progressive kidney metabolism, some of it comes from diet. Anderson, 2010). fibrosis. In old age, whole nephrons (the Foods cooked at high temperature (par- functional units in the kidneys) are ticularly fried or roasted) are high in pro- Reduced glomerular filtration rate replaced by fatty material or scar tissue; on oxidants; it has been suggested that lim- The glomerular filtration rate (GFR) is a average, 70-year-olds have lost 30-50% of iting their intake could reduce oxidative measure of the rate of fluid filtration their nephrons. Aged nephrons often show and inflammatory stress on the kidneys through the glomerular capillaries into a variety of physical defects (Fig 2). (Vlassara et al, 2009). Bowman’s capsule. It is expressed in millili- tres per minute, and is routinely used to Glomerular abnormalities Gender differences in renal ageing measure the progression of kidney disease The number of damaged glomeruli (glo- Although this is still poorly understood, (Bit.ly/RAStagesCKD). GFR peaks in the merulosclerosis) increases, typically oestrogens such as 17 beta-estradiol appear third decade of life, where it may be as high leading to progressive capillary collapse. to protect the renal system in women as 140ml/min/1.73m2. Blood vessel changes Fewer than 5% of glomeruli show sclerosis from the effects of ageing, while andro- progressively reduce renal blood flow and in people in their 20s but, by their 80s, this gens such as testosterone increase the risk GFR: in normal ageing, it drops by around will have risen to around 30% (Weinstein of renal dysfunction in men. One hypoth- 8ml/min per decade after the age of 30. The and Anderson, 2010). esis is that androgens promote fibrosis GFR of people in their 80s may be only in the kidney; this may partially explain 60-70% of what it was when they were Filtration membrane abnormalities why chronic kidney disease progresses young adults; at 90 years of age it has typi- Some nephrons display a progressive more quickly in men (Weinstein and cally fallen to around 65ml/min/1.73m2. thickening and wrinkling of the filtration Anderson, 2010). Reduced GFR means reduced clearance membrane in the glomerulus and Bow- of waste products. However, age-related man’s capsule, decreasing the renal fil- Physiological changes decline in GFR is not observed in all people; tering surface area. The filtration mem- Older people experience a significant indeed many maintain a stable GFR brane also becomes increasingly reduction in renal function. Even in the throughout life, which suggests that vari- permeable, allowing large molecules such absence of disease, some people over the ables other than ageing contribute to the as proteins to collect in the filtrate and age of 65 only possess 60% of the renal CATHERINE HOLLICK CATHERINE decline (Zhou et al, 2008). appear in the urine (proteinuria). function of young adults (Razzaque, 2007). Nursing Times [online] May 2017 / Vol 113 Issue 5 47 www.nursingtimes.net Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice Systems of life This gradual decline has major health Fig 2.
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