Can affect the small vessels in the kidneys
This is more a renal cause of failure
Diabetes, small vessel disease □
Immune glomerulonephritis (streptococcus) □
Get cysts in the kidneys which ruins the architecture of the kidney ◊
General
If you have one allele that is mutated, you get the disease □
Kidney function declines over time
Cycts occur all throughout the tubules of the kidney □
Dominant form
Need both alleles to be mutated to get the disease □
Cyst is at the ascending limb of the LOH □
Recessive form
Polycystic kidney disease (dominant, recessive) □
Malignancy □
Infection □
The strategy is to preserve kidney function as long as possible with dietary change, diuretics and specific therapy □
Interventions are increased as the disease progresses □
Permanent dialysis or transplant is not usually considered until there is no chance of recovering kidney function □
What to do?
Requires kidney function
Position of the kidneys
Renal pelvis □
Ureter (thinning over psoas) □
Urinary bladder □
Right Lower due to liver
This is when you're looking closely at the calises
When there is problems with the kidney, it doesn’t look like a champagne glass anymore
Papillary tips (looks like a champagne glass) □
Note:
Intravenous Pylogram or CT with Contrast
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5 of them … come off the renal artery
Normally they look like a tree □
If the branches spread too far, there is a problem □
Segments are like bronchopulmonary segments … can take it out and you'll still have a 4/5th functioning kidney □
Segmental Arteries of the Kidney
Angiography
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Visualizing the Kidney •
Start sufficiently early to prevent complications of the existing disease
When creatinine clearance equals or is less than 10 ml/min (about 1/12 of normal)
Indicates approaching renal failure
When ○
Dialyzing your blood
Blood goes through tubes which has a semi-tubular membrane … allows solutes but not formed elements to go across it □
Waste products flow into the dialysis solution
Inside the tubes is the blood and outside is the dialysis solution □
Extracorporeal kidney
Hemodialysis □
Visceral and parietal peritoneum are a huge SA for exchange of waste to occur □
Over time waste will flow into the solution … and then can collect the solution and throw it away □
No need to mix the blood with the dialysis solution … apply the dialysis solution right to the peritoneal cavity
Can walk around with the solution in you and go about your normal life □
Ambulatory
Peritoneal dialysis □
Initial do dialysis until transplant available:
Dialysis vs. Transplant
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Can have glucose in the dialysis solution so it diffuses into the blood
□ Mechanisms of Dialysis Dialysis ○ Treatment •
Can have glucose in the dialysis solution so it diffuses into the blood
Dialysis doesn’t stop the progression of the disease
In ESRD, the disease process will continue □
In a small series of patients who go off dialysis and are not suitable for transplant, their renal function has not deteriora ted from the onset of dialysis
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Too little Vitamin D and erythropoietin results
Salt retention and volume expansion contribute to hypertension
Recall the endocrine effects of kidney: … □
Renal Cysts Associated with Dialysis
Reversible situations or where conservative treatment will suffice □
Advance forms of major extra renal disease □
Infection □
Active glomerulonephritis (immune) □
Previous sensitization to donor tissue □
When not to Transplant
From best to worst
□ Twin □ Sibling □ Family member □
“Cadaver” (patients who cannot recover cortical function) □ Unrelated □ Volunteer anonymous □ Possible Donors
You attach to the external iliac
Can also use internal iliac if necessary (not as good)
You don’t attach the kidney to the renal artery □
Kidney will no longer be retroperitoneal
Note: □
Try to emulate the real anatomy of the kidney
Also can insert a stent to maintain the angle ◊
Send the ureter through the wall of the bladder in an oblique manner Ureter Anastomoses □ Logistics of Transplantation Minutes to hours
Immune system attacks someone elses MHC … get damage to endothelium and also get blood clotting ◊
Preexposure to antigen
Damaged endothelium and thrombosis
Make sure that the donor and recipient share MHC alleles. ◊
Prevention
Hyperacute: □
Adaptive immune system … it takes time ◊
1-16 weeks
Damage to both tubules and vessels
Acute □
Vascular
Slow damage to the vasculature of the kidney
Chronic □
Make sure that the donor and recipient match in their MHC alleles
Solution □ Rejection Transplant ○
Blood is basic ○ 7.35-7.45 Normal range ○ Tolerant of acidity Fetus ○ pH •
Humans can have urine that is a pH of 8 and stomach acid of a pH of 1.5 ○
Almost all biological fluids have a very narrow range of pH except for urine ○
The most important fluid to consider is human venous blood and it is normally between 7.35 and 7.45 ○
Alkalosis is a much more rare problem and is almost never fatal. □
Above 7.45 is called physiological alkalosis
Acidosis is a serious problem and can be fatal, at a pH of about 7.0 the CNS becomes so depressed normal functioning ceases □
Below 7.35 is called physiological acidosis
Problems ○
Range of Acidity in Humans •
The ratio in the products and reactants is maintained such that if one of the parts of the equilibrium is removed the reaction moves in such a way as to compensate for the loss.
An equilibrium reactions is a type of reversible chemical reaction wherein both products and reactants are present at the same time. ○
All of the buffers participate in equilibrium reactions so they always act to keep a balance between the reactants and products ○
The buffer consumes H+ so if H+ increase the buffer will consume it
If H+ decreases the buffer will produce H+.
For buffers one of the reactants is H+ thus the buffer systems act to keep H+ in balance ○
Ultimately a buffer system can be completely consumed by attempting to balance large changes in H+ ○
There are both intracellular and extracellular buffers ○
Equilibrium Reactions and Buffers •
E.g. inside of red blood cells haemoglobin (which is constructed partially of the protein globin) is an effective buffer
The carboxyl and amino groups can absorb or give off H+
The buffers give up an H+ in basic conditions and absorb an H+ in acidic conditions thus they buffer or dampen the changes in pH
Inside of cells protein and amino acids act as buffers. ○ Diagram ○ Intracellular Buffers •
In the serum and other extracellular spaces we have the bicarbonate buffer system. This system consists of carbon dioxide, water, carbonic acid, bicarbonate ion and hydrogen ions. The elements of the system are normally always present because CO2 and water are normally present.
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In the urine we have both the phosphate buffer system and the bicarbonate buffer system playing a role. I am not going to write out the phosphate buffer system. ○
Extracellular Buffers •
A. The first thing that happens is that the CO2 combines with water and the carbonic acids levels go up. Next some of the carbonic acid decomposes to yield H+ and bicarbonate. In the end, the increased levels of H+ brings the pH down and the whole system is shifted to the right to maintain a balance in the reactants and products
Q1. What happens within the bicarbonate buffer system when you increase CO2 levels? ○
A. Some of the new H+ combines with the bicarbonate ions in solution to manufacture carbonic acid. Some of the carbonic acid then decomposes to form CO2 and water. The increase in water is insignificant but the CO2 increase is apparent as is the decrease in bicarbonate ion. There is a very modest increase in H+ so the pH will not change very much. Just as in the first slide, the whole system shifted to minimize the change and keep a balance between the products and reactants the difference is that the system shifted to the left to maintain the equilibrium.
Q. What happens when you increase H+ levels? ○
The Dynamic Bicarbonate Buffer System •
CO2Generation and Transport
•