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Case Study: An elderly patient w/a history of osteoporosis, DM II, and…

- - - - 3 Prior conditions & how they relate to the kidneys
        
        Diabetes mellitus II
        
        Cause: High blood glucose levels
        
        Leading to hypertension #
        
        Fats metabolize as a result
        
        Blood levels of fatty acids & their metabolites (keytones) could rise
        
        This could accumulate & cause a drop in blood pH
        
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        High blood pressure
        
        High BP can lead -> chronic high BP
        
        The high pressure can push the platelets against the arteriole walls, thereby weakening them
        
        Stretching of the arteriole walls can lead to scarring
        
        This can lead to damage of the glomerulus
        
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        This could lead to the extraglomerular mesangial cells producing scar tissue being that their job is to regulate signals between cells near the arterioles
        
        Osteoporosis
        
        Due to Ca2+ levels being low, the parathyroid gland releases PTH
        
        PTH stimulates osteoclasts to breakdown the matrix of bone using acid & lysosomal enzymes
        
        Once osteoclasts undergo apoptosis, dissolved osteoid & hydroxypetite are released in blood for reabsorption
        
        However, bone resorption is outpacing bone deposition so that Ca2+ levels are depleted because osteroblasts are not replacing it
        
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  - - - Possible factors leading to this homeostatic imbalance
        
        Poor diet
        
        Not enough Ca2+ in diet
        
        Leading -> osteoporosis
        
        Possibly a diet high in saturated fats & cholesterol
        
        Leading -> High BP
        
        Diet high in sugar
        
        Leading -> DM II
        
        Lack of exercise & sedentary life style
        
        Could contribute to obesity
        
        Genetics
        
        The patient's parents could of experienced DM II, hypertension, or osteoporosis
        
        Or a mixture of some or all of these factors could be the contributor
        
        Chronic stress could have been a factor in either
        
        High BP
        
        The stress hormones released could have raised her BP up
        
        DM II
        
        Eating sugary foods constantly could contribute to the high levels of glucose leading to DM II
        
        Smoking
        
        Nicotine in the cigarette could raise BP while narrowing arteries
        
        Age
        
        This could be a contributor in that a trend for hypertension is seen more in patients over age 40
        
        & due to the patient being in her elderly years could be a contributing factor to on going hypertension
        
        Along w/the statistic that osteoporosis occurs most often in postmenopausal women
- - - - DM II
        
        If DM II leads -> ketoacidosis & this becomes severe enough
        
        While body tries to rid itself of keytones, being that they are negatively charged, much Na+ & K+ could be lost
        
        Too little K+ can cause
        
        Hypokalemia
        
        This could disrupt the APs in the heart
        
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        Respiratory depression
        
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        nonresponsiveness from the hyperpolarization occurring in the ECF
        
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        Too little Na+ can cause
        
        Hyponatremia
        
        Aldosterone deficiency
        
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        Elevation in blood sugar could affect
        
        Glomerular filtration
        
        The excess glucose stick to proteins in vessels
        
        This affects the efferent arteriole in that it gets more narrow
        
        This prevents much blood from leaving glomerulus
        
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        Kidneys in that the excess glucose in the urine filtrate act like an osmotic diuretic (polyuria)
        
        This prevents H2O reabsorption in kidney tubules
        
        Thereby causing much urine output
        
        While decreasing blood vol. & causing dehydration
        
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        DM II can lead to hypertension also
        
        renal artery walls supplying the kidneys w/blood could thicken due to the high pressure in the arteries
        
        Less blood -> kidney
        
        Leading to less O2 -> kidney
        
        Leading to scarring of glomerulus
        
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      - Osteoporosis
        
        The blood is not able to pull much PO4 3- nor Ca2+ from the bones due to the lack of it from osteoclast activity
        
        Hypocalcemia
        
        Lack of Ca2+ increases neuromuscular excitability
        
        Leading -> Muscle tetany
        
        Seizes can occur if severe enough
        
        Effects on cardiovascular sys.
        
        By causing longer QRS intervals
        
        Thereby causing blood congestion in veins returning -> heart
        
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        Due to declining levels of Ca2+ in the blood
        
        This stimulates the parathyroid glands to release more PTH
        
        This affects
        
        Bones
        
        PTH stimulates osteoclasts to breakdown bone matrix
        
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      - High BP
        
        Due to the patient's high BP & or high sugar content in blood #
        
        This can cause damage to the blood vessels overtime
        
        By weakening the arterioles, causing scarring
        
        This could eventually reach the afferent capillaries in the renal corpuscle
        
        Thereby rupturing some of the capillaries, blood could seep into the renal tubule (plasma should be the only substance w/it's ions that should be going through)
        
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        If the enough damage is done, albumin from afferent arteriole could leak into the renal tubule
        
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    - - DM II can affect high BP in that it the high sugar levels in the blood can work w/the high BP levels to weaken blood vessels
        
        Thereby weakening the vessels further
        
        The mixture of the high blood sugar & high BP could affect the vessels in the bones that are already weak from the overactive osteoclasts activivty #
        
        This can possibly rupture the vessels in bone
        
        The vessels in the bones are important for them to remain strong to carry the weight of the body & protect certain organs
        
        If they are weakened further, that puts the patient at risk further for bone fractures besides the osteoporosis that is already putting the patient at risk
        
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- - - - Urinary sys. structures
        
        Kidney
        
        Function: Remove waste from blood and forms urine
        
        They lie in the retroperitoneal region
        
        Kidneys are surrounded by 3 supportive tissue layers
        
        Perirenal fat capsule
        
        A fatty mass that surrounds and cushions kidney's blows
        
        Fibrous capsule
        
        A transparent capsule that prevents infections from spreading to rest of kidney
        
        Renal fascia
        
        Outer layer of dense fibrous connective which anchors kidney & adrenal gland -> other structures
        
        Internal gross anatomy
        
        Renal cortex
        
        Has a granular appearance
        
        Renal medulla
        
        Composed of renal pyramids (aka medullary)
        
        Formed w/bundles of micro. collecting tubules & capillaries
        
        Renal columns
        
        Separate the pyramids
        
        Renal pelvis
        
        Continuous w/the ureter leaving hilum
        
        Major calyces
        
        Branching extensions of pelvis form 2 or 3 of these
        
        These together collect urine
        
        Minor calyces
        
        Each major calyx subdivides into several of these
        
        They enclose the papillae
        
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        Functional units of kidney
        
        Nephrons
        
        Each kidney contains ~ 1 million of these acting together to produce urine
        
        Each nephron creates a cell- & protein-FREE filtrate from blood
        
        Structure of nephron
        
        Cortex
        
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        Medulla
        
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        Classes of nephrons
        
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        Nephron capillary beds
        
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        Juxtaglomerular complex (JGC)
        
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        Renal artery
        
        Deliver 1/4 of tot. CO -> kidneys (1200mL each min)
        
        Renal vein
        
        They carry deoxygenated blood from kidneys -> inferior vena cava -> heart
        
        Renal hilum
        
        Point of attachment for the
        
        Renal vein
        
        Ureter
        
        Renal artery
        
        Ureters
        
        Transport urine from kidneys -> urinary bladder
        
        Urinary bladder
        
        A temp. storage reservoir for urine
        
        Adrenal gland
        
        Produce hormones that regulate responses to stress, metabolism, and immune sys.
        
        Urethra
        
        Tube carrying urine from bladder -> body exterior
    - - Overall function of urinary sys.
        
        The kidneys filter close to 200L of fluid from blood stream in a 24 hr period
        
        They remove
        
        Drugs
        
        Toxins
        
        Nitrogenous wastes
        
        The system secretes EPO for RBC production & rennin to maintain blood pressure
        
        The system maintains pH, electrolytes & fluid balance
        
        Converting Vit D -> active form
        
        Carrying out gluconegenesis during prolonged fasting
      - Key processes of urine formation
        
        II. Tubular reabsorption
        
        This is where the body reclaims what it needs to keep
        
        From Nephron -> blood vessel
        
        It reclaims 99% of what was filtered
        
        Anything not reabsorbed, becomes urine
        
        2) Urine formation of tubular reabsorption
        
        Begins when filtrate enters proximal tubules
        
        Reabsorbed substances follow either
        
        Transcellular route
        
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        Paracellular route
        
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        In the PCT, tight junctions are leaky
        
        Ions that pass -> capillaries
        
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        Nephron loop reabsorbs
        
        Descending limb
        
        H2O
        
        Ascending limb
        
        Cl-
        
        K+
        
        Ca2+
        
        Mg2+
        
        Na+
        
        DCT reabsorbs
        
        Na+
        
        Cl-
        
        Ca2+
        
        Collecting duct reabsorbs
        
        K+
        
        HCO3-
        
        Na+
        
        Cl-
        
        H2O
        
        Urea
        
        Hormones act at the DCT & collecting duct
        
        Aldosterone
        
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        ADH
        
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        ANP
        
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        PTH
        
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        III. Tubular secretion
        
        From blood vessel -> nephron tubule
        
        3) Urine formation of tubular secretion
        
        This process moves selected substances from peritubular capillaries through tubule cells into filtrate
        
        Secretion is important for
        
        Elimination of undesirable substances that have been reabsorbed by passive processes
        
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        Ridding the body of excess K+
        
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        Disposing of substances
        
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        Controlling blood pH
        
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        I. Glomerular filtration
        
        Filtration from blood -> nephron tubule
        
        1) Urine formation of glomerular filtration
        
        A passive process where hydrostatic pressure forces fluids & solutes through a membrane
        
        Filtration membrane
        
        Fenestrated endothelium of glomerular capillaries
        
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        Basement membrane
        
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        Podocytes go to work
        
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        Pressures affecting filtration
        
        Inward pressures
        
        Hydrostatic pressure in capsular space (HP)
        
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        Colloid osmotic pressure in glomerular capillaries (OP)
        
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        Both of theses determine the net filtration pressure (NFP)
        
        Outward pressures
        
        Hydrostatic pressure in capillaries
        
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        Capsular space pressure = zero
        
        Glomerular filtration rate (GFR)
        
        Vol of filtrate formed each min by combined activity of ALL 2 million glomeruli of the kidneys
        
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        Regulation of glomerular filtration
        
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        Occurs at 180L/day
        
        Characteristics
        
        Kidneys process 1200 ml of blood every min
        
        The kidneys consume 20-25% of O2 used by body
        
        Kidneys process ~ 180L of blood daily
        
        Filtrate contains everything in blood plasma except proteins
        
        Urine contains unneeded substances
    - - Diabetes mellitus II
        
        Insulin is present, yet its effects are absent
        
        Glucose levels remain high after meal b/c glucose is unable to be used by cells
        
        Process
        
        When sugars cannot be used as fuel, more fats are mobilized
        
        Resulting in high fatty acid levels in blood (lipidemia)
        
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        3 Cardinal signs DM
        
        Polydipsia
        
        Dehydreation stimulates hypothalamic thirst centers (excessive thirst)
        
        Polyphagia
        
        Although plenty of glucose is available, the body cannot use it
        
        So body breaks down protein & fat to supply energy and this is thought to stimulate appetite
        
        Polyuria #
        
        Excessive glucose in blood leads to excessive glucose in kidney filtrate
        
        Where it acts as an osmotic diuretic (inhibiting H2O reabsorption by kindney tubules)
        
        Results in a lot of urine output which decreases blood volume & causes dehydration
      - Hypertension
        
        Chronically elevated BP
        
        Characterized by sustained or increase in either systolic (above 140mmHg) or diastolic BP (above 90mmHg)
        
        Prolonged, can cause heart failure, vascular disease, renal failure, & stroke
        
        2 types
        
        Primary hypertension
        
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        Secondary hypertension
        
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        Accounts for 90% of cases
      - Osteoporosis
        
        A group of diseases where bone resorption outpaces bone depositon
        
        Composition of bone matrix is normal yet bone mass declines & bones become porous & light
        
        Bones can break easily
        
        Affects entire skeleton
        
        Yet most common fractures are of the vertebrae, neck, & hip
        
        Osteoclasts are breaking down bone & not enough osteoblast are able to replace it