An elderly female patient has a history of osteoporosis, chronic type II diabetes mellitus, and high blood pressure. She has come to the doctor today because she has noticed blood in her urine. Her doctor is now primarily concerned about the effect of high blood pressure on her kidneys and the effect of low kidney function on her already compromised bone mass. What could be going on that explains all of this? How are blood pressure, kidney function, and bone mass related?
Background Information
Upstream Causes
Downstream Effects
Urinary System Anatomy
Urinary System Physiology
Nephrons
General Information on:
DM II
Osteoporosis
Hypertension
Relation to kidney function and other important symptoms/factors
Effects of her different conditions
Kidneys (2)
Ureter (2)
Aorta
Bladder
Inferior Vena Cava
Urethra
Carries the deoxygenated blood from the kidney's and lower half of the body back up to the heart to be reoxygenated
Carries oxygenated blood down to the kidney's and lower half of the body to be filtered and used in the cells
Fist sized, bean shaped organs that filter bodily fluids
Lie on either side of the spine, close to the back
Consist of 3 layers (superficial to deep)
Renal Medulla
Renal Pelvis
Renal Cortex
Specialized cells called NEPHRONS
Ducts that push urine through peristalsis from the kidneys to the bladder
Hollow muscular organ (much like the stomach) that collects and stores urine for disposal
Is flexible, and can hold as much as 1 L of urine, 500 mL comfortably
The duct leading from the bladder out of the body, expelling urine
Microscopic functional unit of the kidney that regulates water and soluble substances by filtration, reabsorption and excretion
Structure
Proximal tube (PCT)
Loop of Henle
Distal tubule (DCT)
Collecting duct
Glomerular Capsule
Glomerulus
"Ball of yarn" that releases ions and other particles to be taken into the nephron and filtered
Surrounds the glomerulus and takes up the filtrate to be processed by the nephron
Located solely in the renal cortex of the kidney
Selective re-absorption of glucose, water and other nutrients
Cells of PCT are ciliated and filled with mitochondria for lots of reabsorption(much like the small intestine)
Creates filtrate
Filtrate
Substance that has passed through a filter
Contains
H20
Salts
HCO3
H+
Urea
Glucose
Amino Acids
Sometimes drugs
Secreted Out
Absorbed in
NaCl
H20
HCO3
Nutrients
K+
H+
NH3
AKA Nephron Loop
Descending Limb
Think ascending segment
Thick ascending segment
Part of the nephron that forms a long loop through the outer and inner medulla of the kidney, where water and salt are primarily reabsorbed into the blood
Connects to the PCT and Thin ascending segment
H2O is secreted out here in the outer medulla
Where the loop turns in the inner medulla and begins to return to the outer medulla
Secretes NaCl
The end of the loop that connects to the distal tubule in the cortex
NaCl is also secreted here as well
Similar to the PCT, leads to the collecting duct
Located solely in the renal cortex
Reabsorbs
Secretes
K+
H+
Calcium
Sodium
Chloride
NaCl
H2O
HCO3
Regulates the pH of urine
Located at the end of the nepron tube chain, in the inner medulla
Aquaporins
ADH (anti-diuretic hormone) triggers the movement of aquaporins to the side of the cell they aren't on here, allowing reabsorption and secretion to take place
Special protein channels in the cell membranes that help transport water in and out of the cell
Help in the collecting duct so more water can leave the urine
Alcohol and caffeine inhibit ADH it means less water is released when they are consumed
Secretes
NaCl
Urea
H2O
Also located in the descending part of the loop of henle
Kidneys
Ureters
Bladder
Urethra
Remove waste products and drugs from the body by filtering them through specialized neprhon cells
Balance bodily fluids
Release hormones to regulate blood pressure
Help control the production of red blood cells
Urea with water and other solutes forms urine and is passed through nephrons down the renal tubes of the kidneys
Two narrow tubes connected to either of the kidneys that move urine via peristalsis down to the bladder
Walls that relax and expand to release and store urine
Send neural signals to brain to signal when it's time to urinate
Pontine storage area
Pontine micturition center
Red light
Green light
Sphincter muscles
Keep urine from leaking out by closing tightly around the bladder opening
Final tube at the end of the urinary system that allows for urine to be excreted from the body
Neural signals tell the bladder and sphincter muscles to relax which allows for urination
Trigone
Lateral walls
Dome
Posterior walls
Triangle shaped area where the urethra meets the bladder
right and left walls on either side of the trigone
Back wall
Roof of the bladder
Abnormally high blood pressure (when the pressure against the arterial walls is too high)
Generally classified as anything 140/90 or higher
Often has no symptoms, but if left untreated can lead to heart attack or stroke
Can be maintained with a low sodium diet, exercise and medication
Type 2 Diabetes
A chronic condition that affects the way the body process' blood sugar
The body doesn't produce enough insulin, but is generally characterized as a bodily resistance to insulin
Not innate, or genetically inherited, but can occur overtime generally due to a high sugar diet
A condition where the bones become weak and brittle
New bone creation doesn't keep up with bone removal, bone remodeling moves faster than creation
Density and quality of bone are reduced
As bones become more fragile, the risk of fracture is greatly increased
Often no symptoms until the first bone break occurs
Indirect Causes
Direct Causes
Osteoporosis
Hypertension
DM II
Effects of her disorders on Kidneys
Further Effects of the medical problems
How do the conditions affect each other
Blood in urine?
If left untreated?
Can lead to urinary tract infections
Since the glucose isn't being properly absorbed into her body due to insulin resistance, her kidney's will simply filter it out
Can impact blood flow, nerves and sensory function in the body, messing with the Kidney's ability to filter blood
Overtime, damage to kidney's and waste buildup in the blood
Diabetic Kidney Disease (very common in people with diabetes, high risk)
Chronic Kidney Disease (CKD)
Many of the medications that are out there to treat osteoporosis have a significant effect on renal function
Can cause kidney stones (your body passes more calcium due to your bones breaking down faster than they can grow)
Second leading cause of kidney failure
Over time it can cause the arteries surrounding the kidneys to narrow, weaken or harden
Could also be a symptom of kidney disease to begin with
Kidney's help in controlling blood pressure by removing waste products and excess water
THE BLOOD IN HER URINE
Her age
Her diet needs to be considered
The medication she may be taking for her amalgamation of conditions
The amount of physical activity she does
The conditions each have a significant impact on the kidneys
2/3 cause some form of kidney disease
Hypertension can cause the kidney's to weaken or grow hard which hinders their function
The same hindrance of function listed in the upstream causes
DM II causes an excess of glucose to exit the body, which leads to an increase of filtrate in her kidney's which could lead to a ride in blood pressure
Hypertension can lead to an increase in calcium secretion which can lead to an acceleration in osteoporosis
Hypertension can lead to an increase in risk for DM II and is present in over 50% of patients with diabetes
Diabetes increases osteoclast function but decreases osteoblast function which leads to accelerated bone loss and ultimately osteoporosis
Could be caused by Kidney Stones from excessive breaking down or improper removal of minerals
Kidney Infection (or UTI)
Kidney Disease
Kidney disease (which could also be causing the hypertension)
The Diabetes seems most likely to be the underlying/root cause for many of her other issues
Diabetes is oftentimes linked with Diabetic Kidney Disease which can lead to a rise in hypertension and blood in the urine
The osteoporosis most likely stems from her age and the affected osteoclasts/blasts from the diabetes
Each of her issues can be treated with it's own independent medicines, which can have an array of side effects
Medication is processed in the kidney's, so an abundance could cause damage
Blood in the urine is a symptom of something underlying
Ultimately, with her kidney's at such high risk from her other ailments, her kidney's will eventually shut down
No kidney's = no waste processing
No waste processing = buildup of waste/toxins in the blood
Medication, proper diet, and mild exercise so she doesn't hurt herself would aid in reducing her symptoms
Improving her water intake might also aid in her problems as well, as Diabetes can leave you dehydrated in the first place