Lane A Case Study in Renal Physiology Melissa

Lane: A Case Study in Renal Physiology Melissa Scott Mountain Brook High School 3650 Bethune Drive Birmingham, AL 35223 scottme@mtnbrook. k 12. al. us Melissa Scott, Mtn. Brook H. S.

LANE Date of Birth - 2/5/99 4. 177 kg, 51 cm Melissa Scott, Mtn. Brook H. S. 2

Hypoplastic right kidney- multicyctic dysplasia. This was diagnosed at 21 weeks in utero. www. pathology. vcu. edu/education/renal/lab 1. m. html Melissa Scott, Mtn. Brook H. S. Multicyctic Dysplasia 3

Lane was seen just after birth by a nephrologist. He was diagnosed with Hypervitaminosis D. -What other mineral imbalance can this lead to that affects the kidney? -How does it affect the kidney? Melissa Scott, Mtn. Brook H. S. 4

Use a concept map to show the relationship between increased phosphates, increased 1, 25 dihydroxy vitamin D and restoration of calcium balance in the blood. Melissa Scott, Mtn. Brook H. S. 5

Use these choices to fill in the concept map: Increased phosphate Increased PTH secretion Increased calcium absorption in the intestine Increased renal calcium absorption Increased release of calcium from bone Increased synthesis of 1, 25 (OH)2 vitamin D Decreased bone resorption of calcium Restoration of plasma calcium balance Melissa Scott, Mtn. Brook H. S. 6

Baseline readings 2/5/99 Sodium Potassium Chloride Bicarbonate Calcium Phosphorus BUN Creatinine Lane’s Plasma Values 139 5. 5 100 23 9. 4 5. 9 9 Melissa Scott, Mtn. Brook H. S. 1. 0 Normal Plasma Values 134 -145 3. 3 -4. 6 98 -110 22 -30 8. 7 -9. 8 3. 8 -6. 5 5 -17 7 0. 3 -0. 7

2/8/99 Upon being released from the hospital, Lane was prescribed the formula Simliac PM 60/40. Why was PM 60/40 prescribed? (Compare the nutritional label on this product with another infant formula. ) http: //rpdcon 40. ross. com/pn/Pediatric. Products. NSF/web_Ross. com_XML_Pedi atric. Nutrition/FFFAB 5 DDD 92 D 164 E 85256 A 8000754756? Open. Document http: //rpdcon 40. ross. com/pn/Pediatric. Products. NSF/web_Ross. com_XML_Pedi atric. Nutrition/99 A 8 FE 734 DDEC 91985257273000 AB 2 F 3? Open. Document Melissa Scott, Mtn. Brook H. S. 8

2/26/99 Sodium Potassium Calcium Phosphorus Chloride CO 2 BUN Creatinine Lane’s Plasma Values 140 5. 1 10. 5 7. 4 103 28 10 0. 4 Normal Plasma Values 134 -145 3. 3 -4. 6 8. 7 -9. 8 3. 8 -6. 5 98 -110 20 -30 5 -17 0. 3 -0. 7 - What stands out in. Scott, these plasma values? Melissa Mtn. Brook H. S. 9

Because of these values, the nephrologist prescribed Amphojel 320 mg per cc, 2 cc 5 x daily. -What compound is Amphojel? -What mineral does Amphojel control and how? -Why was Amphojel prescribed? Melissa Scott, Mtn. Brook H. S. 10

Print the diagram on the following page. Show the mechanism of calcium reabsorption in the distal convoluted tubule. Show where PTH increases calcium absorption. - What is the release of PTH controlled by? Melissa Scott, Mtn. Brook H. S. 11

Lumen Serosa Interstitium Melissa Scott, Mtn. Brook H. S. Peritubular Capillary 12

Multiple calcium stones were present, some which were too large to pass from the ureter. Since it was deemed that the production of these would continue, the doctor performed a left ureterostomy at three weeks of age. Melissa Scott, Mtn. Brook H. S. kidney. niddk. nih. gov 13

You might notice that Lane is wet on his left side. Diapers are not designed to catch urine on the left side of the abdomen and stomal bags are too large. The alternative that the doctor came up with was to affix maxi pads to the left side of the diaper. Just imagine how happy his father was to hear that addition to the baby bag! Melissa Scott, Mtn. Brook H. S. 14

Lane’s Blood Values Sodium 141 Potassium 4. 4 Chloride 101 Bicarbonate 24 BUN 7 Creatinine 0. 3 Calcium 10. 2 Phosphorus 5. 4 25 OH Vitamin D 25. 1 Melissa Scott, Mtn. Brook H. S. 1, 25 (OH)2 Vitamin D 54 Normal Values 134 -145 3. 3 -4. 6 98 -110 22 -30 5 -17 0. 3 -0. 7 8. 7 -9. 8 3. 8 -6. 5 (Normal) 15 (High Normal)

3/23/99 Left cutaneous ureterostomy (to divert obstructed left collecting system and hopefully improve renal function. Make passage of multiple 4 mm renal stones easier. Hydronephrosis caused by lower calyx renal calculus Melissa Scott, Mtn. Brook H. S. library. med. utah. edu/. . . /RENAHTML/RENAL 005. html 16

On his first birthday, Lane is eating some solid foods, but is not drinking cow’s milk. He continues to use the PM 60/40 for several more months. - Why is he avoiding cow’s milk? Melissa Scott, Mtn. Brook H. S. 17

At 18 months, Lane underwent a right nephrectomy, left ureter reimplantation, and bladder augmentation. Several days after surgery, his oxygen levels suddenly dropped and he became bluish around the mouth. -What is wrong with him? -What would you suggest as treatment? Melissa Scott, Mtn. Brook H. S. 18

Print the next page. -Show the relationship between phosphate and hydrogen ion secretion and bicarbonate reabsorption. -How does this diagram explain renal acidosis? Melissa Scott, Mtn. Brook H. S. 19

Lumen Serosa Interstitium Melissa Scott, Mtn. Brook H. S. Peritubular Capillary 20

Several weeks after the surgery, Lane contracted massive infections that hospitilized him for a month. Here, you can see the central line installed to administer antibiotics at home. Melissa Scott, Mtn. Brook H. S. 21

Lane is now eight years old. The only surgery he has had recently was to repair a blockage where the segment of colon was removed to augment his bladder. He suffers from mild hypertension, but is otherwise healthy and happy! Melissa Scott, Mtn. Brook H. S. 22

References Eaton, D. C. , Pooler, J. P. Vander’s Renal Physiology. Lange Medical Books/Mc. Graw-Hill, 2004. Klauber, G. , Urology, New England Medical Center, Boston, MA. Milner, L. , Nephrology, New England Medical Center, Boston, MA. Navar, L. G. Regulation of Renal Hemodynamics, Advanced Physiology Education 275: 221 -235, 1998. Melissa Scott, Mtn. Brook H. S. 23

Lane was seen just after birth by a nephrologist. He was diagnosed with Hypervitaminosis D. -What other mineral imbalance can this lead to that affects the kidney? -How does it affect the kidney? Melissa Scott, Mtn. Brook H. S. 24

Use these choices to fill in the concept map: Increased phosphate Increased PTH secretion Increased calcium absorption in the intestine Increased renal calcium absorption Increased release of calcium from bone Increased synthesis of 1, 25 (OH)2 vitamin D Decreased bone resorption of calcium Restoration of plasma calcium balance Melissa Scott, Mtn. Brook H. S. 25

2/8/99 Upon being released from the hospital, Lane was prescribed the formula Simliac PM 60/40. Why was PM 60/40 prescribed? (Compare the nutritional label on this product with another infant formula. ) http: //rpdcon 40. ross. com/pn/Pediatric. Products. NSF/web_Ross. com_XML_Pedi atric. Nutrition/FFFAB 5 DDD 92 D 164 E 85256 A 8000754756? Open. Document http: //rpdcon 40. ross. com/pn/Pediatric. Products. NSF/web_Ross. com_XML_Pedi atric. Nutrition/99 A 8 FE 734 DDEC 91985257273000 AB 2 F 3? Open. Document Melissa Scott, Mtn. Brook H. S. 26

- What stands out in these plasma values? Melissa Scott, Mtn. Brook H. S. 27

Because of these values, the nephrologist prescribed Amphojel 320 mg per cc, 2 cc 5 x daily. -What compound is Amphojel? -What mineral does Amphojel control and how? -Why was Amphojel prescribed? Melissa Scott, Mtn. Brook H. S. 28

Print the diagram on the following page. Show the mechanism of calcium reabsorption in the distal convoluted tubule. Show where PTH exerts its control. - What is the release of PTH controlled by? Melissa Scott, Mtn. Brook H. S. 29

Lumen Serosa Interstitium Melissa Scott, Mtn. Brook H. S. Peritubular Capillary 30

On his first birthday, Lane is eating some solid foods, but is not drinking cow’s milk. He continues to use the PM 60/40 for several more months. - Why is he avoiding cow’s milk? Melissa Scott, Mtn. Brook H. S. 31

At 18 months, Lane underwent a right nephrectomy, left ureter reimplantation, and bladder augmentation. Several days after surgery, his oxygen levels suddenly dropped and he became bluish around the mouth. -What is wrong with him? -What would you suggest as treatment? Melissa Scott, Mtn. Brook H. S. 32

Print the next page. -Show the relationship between phosphate and hydrogen ion secretion and bicarbonate reabsorption. -How does this diagram explain renal acidosis? Melissa Scott, Mtn. Brook H. S. 33

Lumen Serosa Interstitium Melissa Scott, Mtn. Brook H. S. Peritubular Capillary 34

www. mkhanna. com Active forms of vitamin D increase intestinal absorption of calcium. This can lead to hypercalcemia which may cause production of renal calculi. If the renal calculi form a blockage, they may cause hydronephrosis. Lane has many stones, some larger than 4 mm. They blocked the left ureter and caused urine to build up in the kidney. Melissa Scott, Mtn. Brook H. S. Severe Hydronephrosis 35 www. pathguy. com/~lulo/lulo 0035. htm

Increased phosphate Increased PTH secretion Increased renal calcium absorption Increased release of calcium from bone Increased synthesis of 1, 25 (OH)2 vitamin D Decreased bone resorption of calcium Increased calcium absorption in the intestine Restoration of plasma calcium balance 36 Melissa Scott, Mtn. Brook H. S.

There is a lower content of electrolytes and protein in the PM 60/40. For patients with any renal dysfunction, this puts less stress on the kidneys due to filtration of these substances. Melissa Scott, Mtn. Brook H. S. 37

Both the calcium and phosphorus values are high. Melissa Scott, Mtn. Brook H. S. 38

Amphojel is aluminum hydroxide. It decreases blood phosphate by binding to phosphates in the digestive system to prevent absorption. Excess phosphorus in the blood causes decalcification of bone and excess calcium is present in the blood. Amphojel may also bind to oxalate (calcium oxalate being the most common type of kidney stones). Amphojel was prescribed to lower the phosphorus, only used for a short time since aluminum can become toxic at relatively low Melissa Scott, Mtn. Brook H. S. levels. 39

Lumen Na Cl Na Ca PTH (released in response to excess phosphate in the blood) K Cl Na Ca ATP Serosa Interstitium K Melissa Scott, Mtn. Brook H. S. Peritubular Capillary Na 40

Cow’s milk is high in both electrolytes and protein. Melissa Scott, Mtn. Brook H. S. 41

Lane is experiencing renal acidosis due to the inability of his solitary kidney to remove phosphate ions and therefore hydrogen ions from his system. Bicarbonate ions are not being returned to the blood to act as a buffer system. Carbon dioxide has also built up, causing oxygen deprivation and cyanosis. He was given oxygen immediately, followed by sodium bicarbonate. Melissa Scott, Mtn. Brook H. S. 42

In renal disease, phosphate is not properly removed by the kidneys. Renal acidosis results since excess hydrogen ions cannot be excreted (hydrogen ions are excreted bound to phosphate). Therefore, water and carbon dioxide do not combine to form hydrogen ions and bicarbonate ions. Bicarbonate is not reabsorbed into the blood to act as a buffer and carbon dioxide builds up if it cannot be compensated by respiration. Melissa Scott, Mtn. Brook H. S. 43

HPO 42 - Lumen H 2 PO 4 - K+ ATP Excreted ATP H+ H+ H 2 O + CO 2 Carbonic anyhdrase H+ + HCO 3 - Serosa Interstitium CO 2 Cl Melissa Scott, Mtn. Brook H. S. Peritubular Capillary 44