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Glomerular Filtration
The kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys: Anatomy are primarily in charge of the maintenance of water and solute homeostasis Homeostasis The processes whereby the internal environment of an organism tends to remain balanced and stable. Cell Injury and Death through the processes of filtration, reabsorption, secretion Secretion Coagulation Studies, and excretion. Glomerular filtration is the process of converting the systemic blood supply into a filtrate, which will ultimately become the urine. Complex regulatory processes ensure that only the appropriate substances in the systemic blood are lost in the urine and that the urine flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure is satisfactorily balanced to maintain adequate systemic volume status Volume Status ACES and RUSH: Resuscitation Ultrasound Protocols. Abnormalities of the glomerulus can cause several clinically important conditions.
Renal Anatomy and Physiology Overview
Glomerular Filtration Rate
Regulation of the Glomerular Filtration Rate
Clinical Assessment of GFR
The GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests is the rate of filtration of plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products through the glomerular membrane. Filtration is 1 of 4 primary mechanisms involved in the regulation of water, electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes, and waste excretion:
Filtration: Plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products is filtered in the glomerular capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology, creating a filtrate that passes through the renal tubules.
Reabsorption: Desirable solutes and water are reabsorbed from the tubule lumens back into the blood.
Secretion Secretion Coagulation Studies: Waste products are intentionally secreted.
Excretion: Remaining filtrate is excreted as urine.
Other renal functions:
Hemodynamic regulation ( renin Renin A highly specific (leu-leu) endopeptidase that generates angiotensin I from its precursor angiotensinogen, leading to a cascade of reactions which elevate blood pressure and increase sodium retention by the kidney in the renin-angiotensin system. Renal Sodium and Water Regulation, prostaglandins Prostaglandins A group of compounds derived from unsaturated 20-carbon fatty acids, primarily arachidonic acid, via the cyclooxygenase pathway. They are extremely potent mediators of a diverse group of physiological processes. Eicosanoids, bradykinin Bradykinin A nonapeptide messenger that is enzymatically produced from kallidin in the blood where it is a potent but short-lived agent of arteriolar dilation and increased capillary permeability. Bradykinin is also released from mast cells during asthma attacks, from gut walls as a gastrointestinal vasodilator, from damaged tissues as a pain signal, and may be a neurotransmitter. Hereditary Angioedema (C1 Esterase Inhibitor Deficiency))
RBC production ( erythropoietin Erythropoietin Glycoprotein hormone, secreted chiefly by the kidney in the adult and the liver in the fetus, that acts on erythroid stem cells of the bone marrow to stimulate proliferation and differentiation. Erythrocytes: Histology)
Bone metabolism Bone metabolism Bone is the primary storage site of calcium in the body; thus, bone metabolism plays a critical role in maintaining normal calcium levels. Bone metabolism (and thus calcium levels) are primarily regulated by 3 hormones, namely, calcitonin, parathyroid hormone (PTH), and vitamin D. Calcium Hemostasis and Bone Metabolism
Overview of the glomerulus:
Blood and filtrate flow through the glomerulus. Blood enters through the afferent arteriole, and as it moves through the glomerular capillaries (which are closely associated with filtering podocytes), a portion of the plasma is filtered across the glomerular barrier into Bowman's space. The filtrate (which becomes the urine) then moves out through the proximal tubule, while the blood that was not filtered (and remains in the vessels) leaves through the efferent arteriole.
Primary renal functions
Kidney layers
Cortex:
Location of the glomeruli and proximal and distal convoluted tubules
Lowest osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation (approximately 300 mOsm/kg)
Outer medulla: middle layer, between the cortex and inner medulla
Inner medulla:
Deepest layer
Contains the loops of Henle
Highest osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation (up to 1200 mOsm/kg)
Renal circulation
Blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure
The renal blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure is as follows (in order):
Aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy → renal artery → interlobar artery → arcuate artery → interlobular artery
Afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology arteriole
Glomerular capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology:
Blood is filtered in the glomerular capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology.
The filtrate enters Bowman's space (ultimately becomes urine).
Efferent Efferent Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology arteriole
Peritubular and vasa recta capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology:
Peritubular capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology: surround the proximal and distal tubules
Vasa recta: surround the loops of Henle
Peritubular and vasa recta capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology are the beginning of venous circulation Circulation The movement of the blood as it is pumped through the cardiovascular system. ABCDE Assessment.
Interlobular vein → arcuate vein → interlobar vein → renal vein → vena cava
Nephrons
Nephrons are the functional units of the kidney
Nephron Nephron The functional units of the kidney, consisting of the glomerulus and the attached tubule. Kidneys: Anatomy segments (in the order through which the filtrate flows):
Bowman's capsule Capsule An envelope of loose gel surrounding a bacterial cell which is associated with the virulence of pathogenic bacteria. Some capsules have a well-defined border, whereas others form a slime layer that trails off into the medium. Most capsules consist of relatively simple polysaccharides but there are some bacteria whose capsules are made of polypeptides. Bacteroides
Proximal convoluted tubule Proximal convoluted tubule The renal tubule portion that extends from the bowman capsule in the kidney cortex into the kidney medulla. The proximal tubule consists of a convoluted proximal segment in the cortex, and a distal straight segment descending into the medulla where it forms the u-shaped loop of henle. Osmotic Diuretics
Proximal straight tubule Proximal straight tubule Tubular System
Loop of Henle Loop of Henle The U-shaped portion of the renal tubule in the kidney medulla, consisting of a descending limb and an ascending limb. It is situated between the proximal kidney tubule and the distal kidney tubule. Tubular System, further divided into:
Thin descending limb
Thin ascending limb
Thick ascending limb Thick ascending limb Renal Sodium and Water Regulation
Distal convoluted tubule Distal convoluted tubule The portion of renal tubule that begins from the enlarged segment of the ascending limb of the loop of henle. It reenters the kidney cortex and forms the convoluted segments of the distal tubule. Gitelman Syndrome
Collecting duct Collecting duct Straight tubes commencing in the radiate part of the kidney cortex where they receive the curved ends of the distal convoluted tubules. In the medulla the collecting tubules of each pyramid converge to join a central tube (duct of bellini) which opens on the summit of the papilla. Renal Cell Carcinoma
Types of nephrons:
Cortical (or superficial): Loops of Henle penetrate only as deep as the outer medulla.
Juxtamedullary:
Nephrons whose loops penetrate all the way into the inner medulla
Allow for ↑ concentration of the urine (due to ↑ osmolality Osmolality Plasma osmolality refers to the combined concentration of all solutes in the blood. Renal Sodium and Water Regulation in the inner medulla)
Nephron anatomy
Blood flow within the nephron
Image: "The two capillary beds" by Phil Schatz. License: CC BY 4.0
Renal blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure (RBF):
Rate at which systemic blood is delivered to the kidney
Roughly equals 1000 mL/min, or 20%–25% of the cardiac output Cardiac output The volume of blood passing through the heart per unit of time. It is usually expressed as liters (volume) per minute so as not to be confused with stroke volume (volume per beat). Cardiac Mechanics
The entire blood volume is delivered to the kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys: Anatomy about every 5 minutes.
Renal plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure (RPF):
Portion of RBF that is only plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products (not cells or proteins Proteins Linear polypeptides that are synthesized on ribosomes and may be further modified, crosslinked, cleaved, or assembled into complex proteins with several subunits. The specific sequence of amino acids determines the shape the polypeptide will take, during protein folding, and the function of the protein. Energy Homeostasis)
This portion of the blood is filtered across the glomerular membrane.
RPF (approximate) = RBF × (1 – hematocrit Hematocrit The volume of packed red blood cells in a blood specimen. The volume is measured by centrifugation in a tube with graduated markings, or with automated blood cell counters. It is an indicator of erythrocyte status in disease. For example, anemia shows a low value; polycythemia, a high value. Neonatal Polycythemia)
Approximately 600 mL/min (assuming an RBF of 1000 mL/min and a hematocrit Hematocrit The volume of packed red blood cells in a blood specimen. The volume is measured by centrifugation in a tube with graduated markings, or with automated blood cell counters. It is an indicator of erythrocyte status in disease. For example, anemia shows a low value; polycythemia, a high value. Neonatal Polycythemia of 40%)
Filtration fraction (FF):
Fraction of the RPF that actually moves across the glomerular membrane
FF = GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests / RPF
Approximately 20% under normal circumstances
Functions and Segments – Urinary System
Blood Supply and Control – Urinary System
Glomerular filtration rate Glomerular filtration rate The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests
The GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests is the volume of plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products filtered by the glomerulus per unit of time. It is the most important laboratory indicator Indicator Methods for assessing flow through a system by injection of a known quantity of an indicator, such as a dye, radionuclide, or chilled liquid, into the system and monitoring its concentration over time at a specific point in the system. Body Fluid Compartments of kidney function.
Normal GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests = 90–120 mL/min in healthy people
Varies with age, sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria, and muscle mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast
Often standardized for body surface area
Is the sum of all filtration rates in all functioning nephrons:
Is a rough assessment of the number of functioning nephrons
↓ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests indicates renal disease.
Plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products moves from the glomerular capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology through the glomerular barrier.
The resulting filtrate (the primary urine) collects in Bowman's space and exits through the tubule lumen.
The remaining blood within the capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology exits through the efferent Efferent Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology arteriole.
Equation 1: GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests = RPF × FF
Assume normal parameters:
RPF = 600 mL/min
FF = 20%
GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests = RPF × FF → 600 mL/min × 20% = 120 mL/min
GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests is a function of:
Renal capillary forces ( Starling forces Starling Forces Capillaries: Histology): hydrostatic and oncotic pressure Oncotic Pressure Edema within the capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology and Bowman's space
Properties of the glomerular barrier
Starling forces Starling Forces Capillaries: Histology
Equation 2: GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests = Kf [ (PGC – PBS) – (πGC – πBS) ]:
Kf: filtration barrier; measure of surface area and glomerular permeability
PGC: glomerular capillary hydrostatic pressure Hydrostatic pressure The pressure due to the weight of fluid. Edema
PBS: Bowman's space hydrostatic pressure Hydrostatic pressure The pressure due to the weight of fluid. Edema
πGC: glomerular capillary oncotic pressure Oncotic Pressure Edema
πBS: Bowman's space oncotic pressure Oncotic Pressure Edema
Glomerular barrier
The glomerular barrier is the filtration structure of the nephron Nephron The functional units of the kidney, consisting of the glomerulus and the attached tubule. Kidneys: Anatomy that surrounds the glomerular capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology and includes the following 3 layers:
Capillary endothelium Endothelium A layer of epithelium that lines the heart, blood vessels (vascular endothelium), lymph vessels (lymphatic endothelium), and the serous cavities of the body. Arteries: Histology:
Walls of the capillary vessels
Fenestrated: contain small windows, approximately 100 nm in size
Coated with anionic glycosaminoglycans and glycoproteins Glycoproteins Conjugated protein-carbohydrate compounds including mucins, mucoid, and amyloid glycoproteins. Basics of Carbohydrates
Glomerular basement membrane Glomerular basement membrane The layer of extracellular matrix that lies between the endothelium of the glomerular capillaries and the podocytes of the inner or visceral layer of the bowman capsule. It is the product of these two cell types. It acts as a physical barrier and an ion-selective filter. Goodpasture Syndrome (GBM):
Intermediate layer formed by the capillary endothelial and podocyte Podocyte Highly differentiated epithelial cells of the visceral layer of bowman capsule of the kidney. They are composed of a cell body with major cell surface extensions and secondary fingerlike extensions called pedicels. They enwrap the kidney glomerulus capillaries with their cell surface extensions forming a filtration structure. The pedicels of neighboring podocytes interdigitate with each other leaving between them filtration slits that are bridged by an extracellular structure impermeable to large macromolecules called the slit diaphragm, and provide the last barrier to protein loss in the kidney. Nephritic Syndrome basal laminas
Negatively charged → favors filtration of cations Cations Positively charged atoms, radicals or groups of atoms which travel to the cathode or negative pole during electrolysis. Electrolytes
Epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium: Histology (podocytes):
Attached to the GBM with multiple foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy processes
Foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy processes interdigitate, forming gaps (or pores) approximately 40 nm in size.
Pores are covered by a membrane called the slit diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy:
A unique form of intercellular junction
Consists of multiple proteins Proteins Linear polypeptides that are synthesized on ribosomes and may be further modified, crosslinked, cleaved, or assembled into complex proteins with several subunits. The specific sequence of amino acids determines the shape the polypeptide will take, during protein folding, and the function of the protein. Energy Homeostasis, including nephrin
Assists in filtration function
Diagram of the glomerular barrier:
A: Fenestrated endothelium of the glomerular capillaries
B: Basal membrane
C: Epithelial layer demonstrating podocyte foot processes and structural proteins creating the slit diaphragm
Starling Forces
The kidney has multiple levels of regulatory mechanisms on the GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests:
Autoregulation Autoregulation Systemic and Special Circulations of the renal blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure overall
Relative constriction and dilation of the afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology and efferent Efferent Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology arterioles Arterioles The smallest divisions of the arteries located between the muscular arteries and the capillaries. Arteries: Histology
Tubuloglomerular feedback
Fine-tuning mechanisms: paracrine, endocrine, and neural
Autoregulation Autoregulation Systemic and Special Circulations of renal blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure
Renal blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure is autoregulated through a localized reflexive process called the myogenic response.
Myogenic response: ↑ BP stretches afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology arterioles Arterioles The smallest divisions of the arteries located between the muscular arteries and the capillaries. Arteries: Histology → activates inward-directed ion channels Channels The Cell: Cell Membrane → depolarization Depolarization Membrane Potential → arteriole contraction
↑ Systemic BP → afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology arteriole vasoconstriction Vasoconstriction The physiological narrowing of blood vessels by contraction of the vascular smooth muscle. Vascular Resistance, Flow, and Mean Arterial Pressure → ↓ RBF
↓ Systemic BP → afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology arteriole vasodilation Vasodilation The physiological widening of blood vessels by relaxing the underlying vascular smooth muscle. Pulmonary Hypertension Drugs → ↑ RBF
Maintains relatively constant RBF within a range of normal mean Mean Mean is the sum of all measurements in a data set divided by the number of measurements in that data set. Measures of Central Tendency and Dispersion arterial BPs (the autoregulatory range)
Stable RBF allows the other regulatory mechanisms (rather than systemic BP) to regulate the GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests.
Impact of mean arterial blood pressure on the flow rate of renal blood flow (RBF) and glomerular filtration rate (GFR):
Notice that within the autoregulatory range, GFR and RBF remain relatively constant.
Glomerular hemodynamics Hemodynamics The movement and the forces involved in the movement of the blood through the cardiovascular system. Vascular Resistance, Flow, and Mean Arterial Pressure
The primary regulation of glomerular filtration occurs within the glomerulus itself by constricting and dilating the afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology and efferent Efferent Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology arterioles Arterioles The smallest divisions of the arteries located between the muscular arteries and the capillaries. Arteries: Histology. This affects the hydrostatic pressure Hydrostatic pressure The pressure due to the weight of fluid. Edema within the glomerular capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology.
Note: This animation does not have sound.
Main parameters:
RBF
Ultrafiltrate pressure (PUF), which correlates with glomerular capillary hydrostatic pressure Hydrostatic pressure The pressure due to the weight of fluid. Edema (PGC)
GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests
Tubular flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure: refers to filtered primary urine leaving Bowman's space
Afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology arteriole:
Think in terms of how changing the inflow of blood affects forward pressure.
Constriction:
Decreases all parameters
↓ Inflow → ↓ RBF → ↓ PUF →↓ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests → ↓ tubular flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure
Dilation:
Increases all parameters
↑ Inflow → ↑ RBF → ↑ PUF → ↑ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests → ↑ tubular flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure
Efferent Efferent Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology arteriole:
Think in terms of how changing outflow affects backward pressure
Constriction: ↓ outflow → ↑ PUF → ↑ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests → ↑ tubular flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure but ↓ RBF
Dilation: ↑ outflow → ↓ PUF → ↓ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests → ↓ tubular flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure but ↑ RBF
Renin Renin A highly specific (leu-leu) endopeptidase that generates angiotensin I from its precursor angiotensinogen, leading to a cascade of reactions which elevate blood pressure and increase sodium retention by the kidney in the renin-angiotensin system. Renal Sodium and Water Regulation–angiotensin– aldosterone Aldosterone A hormone secreted by the adrenal cortex that regulates electrolyte and water balance by increasing the renal retention of sodium and the excretion of potassium. Hyperkalemia system ( RAAS RAAS A blood pressure regulating system of interacting components that include renin; angiotensinogen; angiotensin converting enzyme; angiotensin i; angiotensin ii; and angiotensinase. Renin, an enzyme produced in the kidney, acts on angiotensinogen, an alpha-2 globulin produced by the liver, forming angiotensin I. Angiotensin-converting enzyme, contained in the lung, acts on angiotensin I in the plasma converting it to angiotensin II, an extremely powerful vasoconstrictor. Angiotensin II causes contraction of the arteriolar and renal vascular smooth muscle, leading to retention of salt and water in the kidney and increased arterial blood pressure. In addition, angiotensin II stimulates the release of aldosterone from the adrenal cortex, which in turn also increases salt and water retention in the kidney. Angiotensin-converting enzyme also breaks down bradykinin, a powerful vasodilator and component of the kallikrein-kinin system. Adrenal Hormones):
↓ BP → ↓ afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology arteriole stretch → triggers Triggers Hereditary Angioedema (C1 Esterase Inhibitor Deficiency) release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology of renin Renin A highly specific (leu-leu) endopeptidase that generates angiotensin I from its precursor angiotensinogen, leading to a cascade of reactions which elevate blood pressure and increase sodium retention by the kidney in the renin-angiotensin system. Renal Sodium and Water Regulation from the juxtaglomerular cells within the afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology arterioles Arterioles The smallest divisions of the arteries located between the muscular arteries and the capillaries. Arteries: Histology
↑ Renin Renin A highly specific (leu-leu) endopeptidase that generates angiotensin I from its precursor angiotensinogen, leading to a cascade of reactions which elevate blood pressure and increase sodium retention by the kidney in the renin-angiotensin system. Renal Sodium and Water Regulation → ↑ angiotensin I → ↑ angiotensin II Angiotensin II An octapeptide that is a potent but labile vasoconstrictor. It is produced from angiotensin I after the removal of two amino acids at the c-terminal by angiotensin converting enzyme. The amino acid in position 5 varies in different species. To block vasoconstriction and hypertension effect of angiotensin II, patients are often treated with ace inhibitors or with angiotensin II type 1 receptor blockers. Renal Sodium and Water Regulation:
Systemic vasoconstriction Vasoconstriction The physiological narrowing of blood vessels by contraction of the vascular smooth muscle. Vascular Resistance, Flow, and Mean Arterial Pressure → ↑ BP to maintain RBF
Vasoconstriction Vasoconstriction The physiological narrowing of blood vessels by contraction of the vascular smooth muscle. Vascular Resistance, Flow, and Mean Arterial Pressure of both the afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology and efferent Efferent Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology arterioles Arterioles The smallest divisions of the arteries located between the muscular arteries and the capillaries. Arteries: Histology but with more constriction of the efferent Efferent Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology → ↑ PGC → ↑ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests but ↓ in RBF
Stimulates aldosterone Aldosterone A hormone secreted by the adrenal cortex that regulates electrolyte and water balance by increasing the renal retention of sodium and the excretion of potassium. Hyperkalemia → ↑ Na and water reabsorption → ↑ in systemic BP and RBF
↑ BP has the opposite effects.
Effects of constriction (left) and dilation (right) of the efferent arteriole
Macula Macula An oval area in the retina, 3 to 5 mm in diameter, usually located temporal to the posterior pole of the eye and slightly below the level of the optic disk. It is characterized by the presence of a yellow pigment diffusely permeating the inner layers, contains the fovea centralis in its center, and provides the best phototropic visual acuity. It is devoid of retinal blood vessels, except in its periphery, and receives nourishment from the choriocapillaris of the choroid. Eye: Anatomy densa cells within the tubules can sense tubular flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure and adjust secretion Secretion Coagulation Studies of substances that affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests. This process is called tubuloglomerular feedback.
Macula Macula An oval area in the retina, 3 to 5 mm in diameter, usually located temporal to the posterior pole of the eye and slightly below the level of the optic disk. It is characterized by the presence of a yellow pigment diffusely permeating the inner layers, contains the fovea centralis in its center, and provides the best phototropic visual acuity. It is devoid of retinal blood vessels, except in its periphery, and receives nourishment from the choriocapillaris of the choroid. Eye: Anatomy densa cells (located in distal tubules):
Sense the relative flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure of NaCl, which correlates directly with GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests
↑ NaCl flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure = ↑ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests
Macula Macula An oval area in the retina, 3 to 5 mm in diameter, usually located temporal to the posterior pole of the eye and slightly below the level of the optic disk. It is characterized by the presence of a yellow pigment diffusely permeating the inner layers, contains the fovea centralis in its center, and provides the best phototropic visual acuity. It is devoid of retinal blood vessels, except in its periphery, and receives nourishment from the choriocapillaris of the choroid. Eye: Anatomy densa cells can:
Secrete adenosine Adenosine A nucleoside that is composed of adenine and d-ribose. Adenosine or adenosine derivatives play many important biological roles in addition to being components of DNA and RNA. Adenosine itself is a neurotransmitter. Class 5 Antiarrhythmic Drugs
Independently stimulate juxtaglomerular cells to secrete renin Renin A highly specific (leu-leu) endopeptidase that generates angiotensin I from its precursor angiotensinogen, leading to a cascade of reactions which elevate blood pressure and increase sodium retention by the kidney in the renin-angiotensin system. Renal Sodium and Water Regulation (activate the RAAS RAAS A blood pressure regulating system of interacting components that include renin; angiotensinogen; angiotensin converting enzyme; angiotensin i; angiotensin ii; and angiotensinase. Renin, an enzyme produced in the kidney, acts on angiotensinogen, an alpha-2 globulin produced by the liver, forming angiotensin I. Angiotensin-converting enzyme, contained in the lung, acts on angiotensin I in the plasma converting it to angiotensin II, an extremely powerful vasoconstrictor. Angiotensin II causes contraction of the arteriolar and renal vascular smooth muscle, leading to retention of salt and water in the kidney and increased arterial blood pressure. In addition, angiotensin II stimulates the release of aldosterone from the adrenal cortex, which in turn also increases salt and water retention in the kidney. Angiotensin-converting enzyme also breaks down bradykinin, a powerful vasodilator and component of the kallikrein-kinin system. Adrenal Hormones)
Adenosine Adenosine A nucleoside that is composed of adenine and d-ribose. Adenosine or adenosine derivatives play many important biological roles in addition to being components of DNA and RNA. Adenosine itself is a neurotransmitter. Class 5 Antiarrhythmic Drugs: ↓ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests
Constricts afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology arterioles Arterioles The smallest divisions of the arteries located between the muscular arteries and the capillaries. Arteries: Histology
Dilates efferent Efferent Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology arterioles Arterioles The smallest divisions of the arteries located between the muscular arteries and the capillaries. Arteries: Histology
Renin Renin A highly specific (leu-leu) endopeptidase that generates angiotensin I from its precursor angiotensinogen, leading to a cascade of reactions which elevate blood pressure and increase sodium retention by the kidney in the renin-angiotensin system. Renal Sodium and Water Regulation: ↑ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests (see RAAS RAAS A blood pressure regulating system of interacting components that include renin; angiotensinogen; angiotensin converting enzyme; angiotensin i; angiotensin ii; and angiotensinase. Renin, an enzyme produced in the kidney, acts on angiotensinogen, an alpha-2 globulin produced by the liver, forming angiotensin I. Angiotensin-converting enzyme, contained in the lung, acts on angiotensin I in the plasma converting it to angiotensin II, an extremely powerful vasoconstrictor. Angiotensin II causes contraction of the arteriolar and renal vascular smooth muscle, leading to retention of salt and water in the kidney and increased arterial blood pressure. In addition, angiotensin II stimulates the release of aldosterone from the adrenal cortex, which in turn also increases salt and water retention in the kidney. Angiotensin-converting enzyme also breaks down bradykinin, a powerful vasodilator and component of the kallikrein-kinin system. Adrenal Hormones above)
↑ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests → ↑ tubular NaCl flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure → macula Macula An oval area in the retina, 3 to 5 mm in diameter, usually located temporal to the posterior pole of the eye and slightly below the level of the optic disk. It is characterized by the presence of a yellow pigment diffusely permeating the inner layers, contains the fovea centralis in its center, and provides the best phototropic visual acuity. It is devoid of retinal blood vessels, except in its periphery, and receives nourishment from the choriocapillaris of the choroid. Eye: Anatomy densa cells sense ↑ flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure → release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology adenosine Adenosine A nucleoside that is composed of adenine and d-ribose. Adenosine or adenosine derivatives play many important biological roles in addition to being components of DNA and RNA. Adenosine itself is a neurotransmitter. Class 5 Antiarrhythmic Drugs (and inhibit renin Renin A highly specific (leu-leu) endopeptidase that generates angiotensin I from its precursor angiotensinogen, leading to a cascade of reactions which elevate blood pressure and increase sodium retention by the kidney in the renin-angiotensin system. Renal Sodium and Water Regulation) → GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests ↓ (normalizes)
↓ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests → ↓ tubular NaCl flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure → macula Macula An oval area in the retina, 3 to 5 mm in diameter, usually located temporal to the posterior pole of the eye and slightly below the level of the optic disk. It is characterized by the presence of a yellow pigment diffusely permeating the inner layers, contains the fovea centralis in its center, and provides the best phototropic visual acuity. It is devoid of retinal blood vessels, except in its periphery, and receives nourishment from the choriocapillaris of the choroid. Eye: Anatomy densa cells sense ↓ flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure → stimulate the release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology of renin Renin A highly specific (leu-leu) endopeptidase that generates angiotensin I from its precursor angiotensinogen, leading to a cascade of reactions which elevate blood pressure and increase sodium retention by the kidney in the renin-angiotensin system. Renal Sodium and Water Regulation (and inhibit adenosine Adenosine A nucleoside that is composed of adenine and d-ribose. Adenosine or adenosine derivatives play many important biological roles in addition to being components of DNA and RNA. Adenosine itself is a neurotransmitter. Class 5 Antiarrhythmic Drugs) → GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests ↑ (normalizes)
Metabolic responses of the kidney to high and low tubule flow
AA: afferent arteriole
EA: efferent arteriole
JG: juxtaglomerular
Fine-tuning mechanisms
Paracrine mechanisms:
Arteriole vasoconstrictors (↓ RBF):
Endothelins Endothelins 21-amino-acid peptides produced by vascular endothelial cells and functioning as potent vasoconstrictors. The endothelin family consists of three members, endothelin-1; endothelin-2; and endothelin-3. All three peptides contain 21 amino acids, but vary in amino acid composition. The three peptides produce vasoconstrictor and pressor responses in various parts of the body. However, the quantitative profiles of the pharmacological activities are considerably different among the three isopeptides. Hemostasis
Leukotrienes Leukotrienes A family of biologically active compounds derived from arachidonic acid by oxidative metabolism through the 5-lipoxygenase pathway. They participate in host defense reactions and pathophysiological conditions such as immediate hypersensitivity and inflammation. They have potent actions on many essential organs and systems, including the cardiovascular, pulmonary, and central nervous system as well as the gastrointestinal tract and the immune system. Eicosanoids
Arteriole vasodilators Vasodilators Drugs used to cause dilation of the blood vessels. Thromboangiitis Obliterans (Buerger's Disease) (↑ RBF):
Prostaglandins Prostaglandins A group of compounds derived from unsaturated 20-carbon fatty acids, primarily arachidonic acid, via the cyclooxygenase pathway. They are extremely potent mediators of a diverse group of physiological processes. Eicosanoids
Endocrine mechanisms:
Angiotensin II Angiotensin II An octapeptide that is a potent but labile vasoconstrictor. It is produced from angiotensin I after the removal of two amino acids at the c-terminal by angiotensin converting enzyme. The amino acid in position 5 varies in different species. To block vasoconstriction and hypertension effect of angiotensin II, patients are often treated with ace inhibitors or with angiotensin II type 1 receptor blockers. Renal Sodium and Water Regulation: ↑ glomerular hydrostatic pressure Hydrostatic pressure The pressure due to the weight of fluid. Edema due to preferential constriction of the efferent Efferent Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology arteriole → ↑ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests but ↓ RBF
Atrial natriuretic peptide Atrial natriuretic peptide A potent natriuretic and vasodilatory peptide or mixture of different-sized low molecular weight peptides derived from a common precursor and secreted mainly by the heart atrium. All these peptides share a sequence of about 20 amino acids. Renal Sodium and Water Regulation (ANP): vasodilation Vasodilation The physiological widening of blood vessels by relaxing the underlying vascular smooth muscle. Pulmonary Hypertension Drugs of the afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology arteriole → ↑ GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests and ↑ RBF
Neural mechanisms:
Sympathetic nervous system Nervous system The nervous system is a small and complex system that consists of an intricate network of neural cells (or neurons) and even more glial cells (for support and insulation). It is divided according to its anatomical components as well as its functional characteristics. The brain and spinal cord are referred to as the central nervous system, and the branches of nerves from these structures are referred to as the peripheral nervous system. Nervous System: Anatomy, Structure, and Classification–mediated vasoconstriction Vasoconstriction The physiological narrowing of blood vessels by contraction of the vascular smooth muscle. Vascular Resistance, Flow, and Mean Arterial Pressure of arterioles Arterioles The smallest divisions of the arteries located between the muscular arteries and the capillaries. Arteries: Histology → ↓ RBF
Epinephrine Epinephrine The active sympathomimetic hormone from the adrenal medulla. It stimulates both the alpha- and beta- adrenergic systems, causes systemic vasoconstriction and gastrointestinal relaxation, stimulates the heart, and dilates bronchi and cerebral vessels. Sympathomimetic Drugs, norepinephrine Norepinephrine Precursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic sympathetic fibers, and of the diffuse projection system in the brain that arises from the locus ceruleus. Receptors and Neurotransmitters of the CNS
Afferent and Efferent Arterioles
Regulation of GFR and RBF
Clearance describes the amount of plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products volume that is completely cleared of a particular substance per unit of time. Clearance equals GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests with substances that are freely filtered (not blocked by the glomerular barrier), not reabsorbed, and not secreted.
Renal clearance Renal Clearance Pharmacokinetics and Pharmacodynamics formula
Cx = Ux ⋅ V/Px
Cx is the clearance of substance x (e.g., creatinine).
Ux is the urine concentration of substance x.
Px is the plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products concentration of substance x.
V is the urine flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure rate.
Substances used to measure clearance
Inulin:
A nonendogenous polysaccharide (must be given IV)
An ideal indicator Indicator Methods for assessing flow through a system by injection of a known quantity of an indicator, such as a dye, radionuclide, or chilled liquid, into the system and monitoring its concentration over time at a specific point in the system. Body Fluid Compartments for GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests because it is:
Freely filtered
Not reabsorbed
Not secreted
Used for research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest purposes, but not commonly used in clinical practice
Creatinine:
A by-product of muscle metabolism
Good indicator Indicator Methods for assessing flow through a system by injection of a known quantity of an indicator, such as a dye, radionuclide, or chilled liquid, into the system and monitoring its concentration over time at a specific point in the system. Body Fluid Compartments for GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests:
Small amount secreted: slight tendency to overestimate GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests (because some is cleared by secretion Secretion Coagulation Studies rather than filtration)
Clinical standard for GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests estimation and overall kidney function:
Endogenous product Product A molecule created by the enzymatic reaction. Basics of Enzymes of muscle metabolism
Easily measured on routine blood tests (e.g., basic metabolic panel Basic Metabolic Panel Primary vs Secondary Headaches)
Can easily adjust for slight inaccuracy from secretion Secretion Coagulation Studies effect
Para-amino hippurate (PAH):
Ideal indicator Indicator Methods for assessing flow through a system by injection of a known quantity of an indicator, such as a dye, radionuclide, or chilled liquid, into the system and monitoring its concentration over time at a specific point in the system. Body Fluid Compartments for RPF (freely filtered, not reabsorbed, fully secreted)
Not endogenous (must be given IV)
Not commonly used in practice
Properties of inulin as a measure of clearance
Renal Clearance Equations
24-hour urine collection for creatinine clearance Creatinine clearance Kidney Function Tests
Clinical gold standard for GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests assessment
Can be impractical:
Patient must be motivated to collect all urine for 24 hours.
Takes several days to get results
Common to have incomplete urine collections, which are difficult to interpret
Sometimes done if very accurate GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests measurement is desired (e.g., prior to starting dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Peritoneal Dialysis and Hemodialysis)
Serum creatinine is typically what is used for GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests determination, owing to its ease of collection and rapid turnaround time.
An inverse logarithmic relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship exists between serum creatinine and GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests.
Increase in Cr from 1 to 2 = approximately 50% decrease in GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests, but
Increase in Cr from 4 to 5 = relatively small decrease in GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests
Clinical implications:
Small changes in serum creatinine must be attended to vigilantly.
Dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Peritoneal Dialysis and Hemodialysis/transplantation are often considered once serum creatinine is consistently > 4 mg/dL.
Serum creatinine can be falsely elevated: will not have corresponding ↑ in serum BUN
↑ Tubular secretion Secretion Coagulation Studies of creatinine: trimethoprim Trimethoprim The sulfonamides are a class of antimicrobial drugs inhibiting folic acid synthesize in pathogens. The prototypical drug in the class is sulfamethoxazole. Although not technically sulfonamides, trimethoprim, dapsone, and pyrimethamine are also important antimicrobial agents inhibiting folic acid synthesis. The agents are often combined with sulfonamides, resulting in a synergistic effect. Sulfonamides and Trimethoprim, cimetidine Cimetidine A histamine congener, it competitively inhibits histamine binding to histamine h2 receptors. Cimetidine has a range of pharmacological actions. It inhibits gastric acid secretion, as well as pepsin and gastrin output. Antihistamines
Lab assay interference: acetoacetate Acetoacetate Salts and derivatives of acetoacetic acid. Ketone Body Metabolism (in diabetic ketoacidosis Ketoacidosis A life-threatening complication of diabetes mellitus, primarily of type 1 diabetes mellitus with severe insulin deficiency and extreme hyperglycemia. It is characterized by ketosis; dehydration; and depressed consciousness leading to coma. Metabolic Acidosis ( DKA DKA Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are serious, acute complications of diabetes mellitus. Diabetic ketoacidosis is characterized by hyperglycemia and ketoacidosis due to an absolute insulin deficiency. Hyperglycemic Crises)), cefoxitin, flucytosine Flucytosine Flucytosine is a pyrimidine analog that disrupts fungal DNA and RNA synthesis. Flucytosine is always used in combination with other antifungal agents and is primarily used to treat cryptococcal meningitis. Flucytosine, Griseofulvin, and Terbinafine
↑ Production of creatinine: excessive intake of creatine Creatine An amino acid that occurs in vertebrate tissues and in urine. In muscle tissue, creatine generally occurs as phosphocreatine. Creatine is excreted as creatinine in the urine. Acute Kidney Injury (dietary supplement), injury to skeletal muscle
Serum creatinine can have true changes in several common circumstances other than AKI AKI Acute kidney injury refers to sudden and often reversible loss of renal function, which develops over days or weeks. Azotemia refers to elevated levels of nitrogen-containing substances in the blood that accompany AKI, which include BUN and creatinine. Acute Kidney Injury or CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease:
Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care:
Decreases slightly during 1st and 2nd trimesters
Returns to prepregnancy value in 3rd trimester
Aging:
Rises very slowly with age
GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests can decrease by 0.5–1 mL/min/year in healthy adults.
Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus:
Serum creatinine decreases early in the disease course owing to hyperfiltration Hyperfiltration Chronic Kidney Disease.
Over time, hyperfiltration Hyperfiltration Chronic Kidney Disease causes damage and results in elevated serum creatinine.
Very low muscle mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast: cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Cirrhosis, malnutrition Malnutrition Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema). Malnutrition in children in resource-limited countries, amputation Amputation An amputation is the separation of a portion of the limb or the entire limb from the body, along with the bone. Amputations are generally indicated for conditions that compromise the viability of the limb or promote the spread of a local process that could manifest systemically. Amputation:
Often have serum creatinine < 0.5 at baseline
GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests equations will overestimate true kidney function.
Small changes (e.g., serum creatinine 0.5 → 1) represent severe AKI AKI Acute kidney injury refers to sudden and often reversible loss of renal function, which develops over days or weeks. Azotemia refers to elevated levels of nitrogen-containing substances in the blood that accompany AKI, which include BUN and creatinine. Acute Kidney Injury in these patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship (commonly missed by clinicians).
Relationship between creatinine and GFR
eGFR: estimated GFR
Estimated glomerular filtration rate Glomerular filtration rate The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests from serum creatinine
Most common clinical indicator Indicator Methods for assessing flow through a system by injection of a known quantity of an indicator, such as a dye, radionuclide, or chilled liquid, into the system and monitoring its concentration over time at a specific point in the system. Body Fluid Compartments of GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests
Several formulas have been developed and validated:
Cockcroft–Gault, Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Chronic Kidney Disease Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)
Input variables: serum creatinine, age, sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria, race (correlates with muscle mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast)
Note: the 2021 revised CKD-EPI equation:
No longer includes race
Is now recommended by the National Kidney Foundation to estimate GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests
Formulas are accurate only in steady-state conditions:
Accurate in CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease
Not accurate in AKI AKI Acute kidney injury refers to sudden and often reversible loss of renal function, which develops over days or weeks. Azotemia refers to elevated levels of nitrogen-containing substances in the blood that accompany AKI, which include BUN and creatinine. Acute Kidney Injury
In practice, simple online calculators are used for this formula.
eGFR is used to stage chronic kidney disease Chronic Kidney Disease Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease:
Stage 1 Stage 1 Trypanosoma brucei/African trypanosomiasis: GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests ≥ 90 mL/min/1.73 m2
Stage 2: GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests 60–89 mL/min/1.73 m2
Stage 5: GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman's capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests < 15 mL/min/1.73 m2
eGFR is also commonly used to adjust drug dosages for kidney function.
Glomerular filtration is most commonly used to assess overall kidney function and to stratify CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease into stages. Additionally, there are specific disease processes of the glomerulus that impair filtration. Diseases are typically categorized as nephrotic (primarily proteinuria Proteinuria The presence of proteins in the urine, an indicator of kidney diseases. Nephrotic Syndrome in Children) or nephritic (primarily hematuria Hematuria Presence of blood in the urine. Renal Cell Carcinoma).
ANCA ANCA Group of systemic vasculitis with a strong association with anca. The disorders are characterized by necrotizing inflammation of small and medium size vessels, with little or no immune-complex deposits in vessel walls. Rapidly Progressive Glomerulonephritis vasculitis Vasculitis Inflammation of any one of the blood vessels, including the arteries; veins; and rest of the vasculature system in the body. Systemic Lupus Erythematosus: This vasculitis Vasculitis Inflammation of any one of the blood vessels, including the arteries; veins; and rest of the vasculature system in the body. Systemic Lupus Erythematosus is a necrotizing vasculitis Vasculitis Inflammation of any one of the blood vessels, including the arteries; veins; and rest of the vasculature system in the body. Systemic Lupus Erythematosus affecting small vessels, including the capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology of the glomerulus.
Alport syndrome Alport Syndrome Alport syndrome, also called hereditary nephritis, is a genetic disorder caused by a mutation in the genes encoding for the alpha chains of type IV collagen, resulting in the production of abnormal type IV collagen strands. Patients present with glomerulonephritis, hypertension, edema, hematuria, and proteinuria, as well as with ocular and auditory findings. Alport Syndrome: a genetic condition resulting in abnormal type IV collagen Collagen A polypeptide substance comprising about one third of the total protein in mammalian organisms. It is the main constituent of skin; connective tissue; and the organic substance of bones (bone and bones) and teeth (tooth). Connective Tissue: Histology, which affects the GBM, in addition to the cochlea Cochlea The part of the inner ear (labyrinth) that is concerned with hearing. It forms the anterior part of the labyrinth, as a snail-like structure that is situated almost horizontally anterior to the vestibular labyrinth. Ear: Anatomy and eye, leading to progressive renal dysfunction, sensorineural hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss and ocular abnormalities.
Anti-GBM disease (Goodpasture's disease): This rare small-vessel vasculitis Small-Vessel Vasculitis Henoch-Schönlein Purpura with polyclonal circulating antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: Types and Functions directed against antigens within the GBM results in a rapidly progressive glomerulonephritis Rapidly Progressive Glomerulonephritis Rapidly progressive glomerulonephritis (RPGN) is a syndrome of severe glomerular disease with progressive loss of kidney function within weeks to months. Histologically, crescents (the proliferation of epithelial cells and the infiltration of monocytes/macrophages in the Bowman space) are found in the glomeruli and arise from immunologic injury. Rapidly Progressive Glomerulonephritis and/or alveolar hemorrhage.
Minimal change disease Minimal change disease Minimal change disease (MCD), also known as lipoid nephrosis, is the most common cause of nephrotic syndrome in children. The designation "minimal change" comes from the very little changes noticed in kidney biopsies under light microscopy. Hallmark clinical findings include edema, proteinuria, hypoalbuminemia, and hyperlipidemia. Minimal Change Disease: a major cause of nephrotic syndrome Nephrotic syndrome Nephrotic syndrome is characterized by severe proteinuria, hypoalbuminemia, and peripheral edema. In contrast, the nephritic syndromes present with hematuria, variable loss of renal function, and hypertension, although there is sometimes overlap of > 1 glomerular disease in the same individual. Nephrotic Syndrome caused by fusion (retraction, widening, and shortening) of the foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy processes in podocytes: The underlying cause of minimal change disease Minimal change disease Minimal change disease (MCD), also known as lipoid nephrosis, is the most common cause of nephrotic syndrome in children. The designation "minimal change" comes from the very little changes noticed in kidney biopsies under light microscopy. Hallmark clinical findings include edema, proteinuria, hypoalbuminemia, and hyperlipidemia. Minimal Change Disease is unclear, but evidence suggests that T-cell dysfunction may play a causative role. Treatment generally involves glucocorticoids Glucocorticoids Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. Glucocorticoids.
Membranous nephropathy: a common cause of nephrotic syndrome Nephrotic syndrome Nephrotic syndrome is characterized by severe proteinuria, hypoalbuminemia, and peripheral edema. In contrast, the nephritic syndromes present with hematuria, variable loss of renal function, and hypertension, although there is sometimes overlap of > 1 glomerular disease in the same individual. Nephrotic Syndrome resulting from thickening of the GBM due to immune deposits of IgG IgG The major immunoglobulin isotype class in normal human serum. There are several isotype subclasses of igg, for example, igg1, igg2a, and igg2b. Hypersensitivity Pneumonitis antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: Types and Functions directed against antigens on the podocyte Podocyte Highly differentiated epithelial cells of the visceral layer of bowman capsule of the kidney. They are composed of a cell body with major cell surface extensions and secondary fingerlike extensions called pedicels. They enwrap the kidney glomerulus capillaries with their cell surface extensions forming a filtration structure. The pedicels of neighboring podocytes interdigitate with each other leaving between them filtration slits that are bridged by an extracellular structure impermeable to large macromolecules called the slit diaphragm, and provide the last barrier to protein loss in the kidney. Nephritic Syndrome foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy processes.
Inker LA, Astor BC, Fox CH, et al. (2014). KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD. American Journal of Kidney Diseases 63:713–735. https://doi.org/10.1053/j.ajkd.2014.01.416
Inker LA, Perrone RD. (2020). Assessment of kidney function. UpToDate. Retrieved March 7, 2021, from https://www.uptodate.com/contents/assessment-of-kidney-function
Inker LA, Perrone RD. (2020). Drugs that elevate the serum creatinine concentration. UpToDate. Retrieved March 7, 2021, from https://www.uptodate.com/contents/drugs-that-elevate-the-serum-creatinine-concentration
Kidney Disease: Improving Global Outcomes (KDIGO). (2012). Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD). https://kdigo.org/guidelines/ckd-evaluation-and-management/
Renal functions, basic processes, and anatomy. (2018). In Eaton DC, Pooler JP (Eds.), Vander's Renal Physiology, 9th ed. McGraw-Hill.
Renal blood flow and glomerular filtration. (2018). In Eaton DC, Pooler JP (Eds.), Vander's Renal Physiology, 9th ed. McGraw-Hill.
Schwandt A, Denkinger M, Fasching P, et al. (2017). Comparison of MDRD, CKD-EPI, and Cockcroft-Gault equation in relation to measured glomerular filtration rate among a large cohort with diabetes. Journal of Diabetes and Its Complications 31:1376–1383. https://doi.org/10.1016/j.jdiacomp.2017.06.016
Thadhani RI, Maynard SE. (2020). Maternal adaptations to pregnancy: renal and urinary tract physiology. UpToDate. Retrieved March 7, 2021, from https://www.uptodate.com/contents/maternal-adaptations-to-pregnancy-renal-and-urinary-tract-physiology


There are many recognizable stars in this year's film selections of the Southern Utah University's Thunderbird International Film Festival (TIFF). The opening film, "In the Daytime, the Stars will Shine," is a musical documentary following the son of British glam-rock superstar, Marc Bolan, as he returns to England to discover his heritage after his father's tragic death, and being raised in America.
A second film, "Rats & Bullies," is a documentary dealing with the currently-prominent issue of youth rivalry. Rats & Bullies is about a 14-year old girl in Canada who kills herself rather than "rat out" the "mean girls" who had been bullying her. And, "A Pioneer Miracle" tells the true story of a young Mormon pioneer girl whose life is saved by a miracle, teaching her a lesson about faith and forgiveness.
Besides its attention to timely issues, Thunderbird sets itself apart in the film festival circuit other reasons, too. Foremost on the list is its system of submission breakdown. Divisions are delineated by skill level: Student, Master Thesis, First Film and Professional. Categories include: Action, Comedy, Documentary, Drama and Open Genre. Thirty minutes is the breaking point between Short and Long.
TIFF '04 is screening 28 films. Four of these, on 35 mm, will be shown at the Cedar Twin Theater. The rest of the films will show at the SUU Sharwan Smith Theatre on a state-of-the-art digital projection system.
Tickets are $10 for each screening, which contain more than one film. A Moviemania Pass can be purchased for $50 for access to all films throughout the entire Festival.


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Home Sports Bucs, Jags land in preseason rankings
Bucs, Jags land in preseason rankings
by KYLE PARMLEY
Photo by Barry Stephenson.
Josh Niblett
The Bucs are not the top-ranked team in the ASWA preseason poll for the first time since 2000.
The Alabama Sports Writers Association released its preseason football poll last week, and it featured an unusual sight.
Hoover has been the top-ranked team in either Class 6A or 7A in every preseason poll since 2000, but McGill-Toolen snapped that streak this year, as the defending 7A champs are the No. 1 team to start the year. James Clemens was ranked second.
The Bucs find themselves at No. 3 to begin the year, receiving one first-place vote among the 30 cast.
Spain Park knocked off Hoover to reach the state final against McGill-Toolen last fall, and the Jags are slotted at No. 5 to kick off the season.
Hoover's first opponent of the season, Central-Phenix City, slid in between the Bucs and Jags at No. 4.
Bob Jones, Hewitt-Trussville, Murphy, Auburn, and Gadsden City rounded out the top 10.
Vestavia Hills was the only other Region 3 team to receive votes outside of Hoover and Spain Park.
Spain Park Football Hoover Football Hoover High School Sports ASWA football poll Spain Park High School

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Goldman Sachs analyst James Schneider upgraded TSYS to Buy from Neutral and raised his price target for the shares to $115 from $98. The company's new portfolios are driving revenue growth while improving margin expansion is driving earnings acceleration, Schneider tells investors in a research note. As a result, the analyst expects TSYS' valuation discount relative to peers to narrow.
KeyBanc analyst Josh Beck raised his price target for TSYS to $95 from $90 and reiterated an Overweight rating on the shares. The analyst notes the company finished the year on "solid footing," topping EPS though revenue was closer to in line.
TSYS reported "very strong" Q4 but management's communication regarding merchant acquiring organic growth was deficient, Nomura Instinet analyst Dan Dolev tells investors in a post-earnings research note. Not quantifying ASC 606 or the impact of acquisitions led to confusion as it unnecessarily implied lower organic growth, says the analyst. He keeps a Buy rating on TSYS.
Citi analyst Ashwin Shirvaikar made changes to his stock rankings in the Payments, Processors & IT Services space following FIS' (FIS) acquisition of Worldpay (WP). Global Payments (GPN) and TSYS (TSS) rise towards the top of the analyst's list. Both are "solid" stand-alone ideas but investors should also discuss whether M&A makes sense for either or both names, Shirvaikar tells investors in a research note. The other change made by the analyst was to swap in Square (SQ) to his highest tranche, or "Elite Eight," instead of FleetCor (FLT).


Well, now the Texas School Jam competition is coming to an end. The administrator is stating that it is a very close race. Your vote these last 10 days could propel Livvy's band, AFTERMATH, into the finals. Livvy's band was fortunate enough to be picked as one of the semi-finalists. The top six bands with the most votes goes to the finals. If they progress to the finals and win they will be going to Germany to perform on MTV!!!
Also the winner's school's music program gets a nice grant. We would really appreciate your vote. Please feel free to pass this along to anyone who might be interested.
If you have a moment Livvy's band AfterMath would greatly appreciate your vote. You can vote every 24 hour period, every day. There is also a star rating that you can choose.
Thank you for helping Livvy win!


Before Christian Serratos laced up her boots to play Rosita on The Walking Dead, she admits she had never seen the show. That changed quickly, however, and she now considers herself a "die-hard" fan of the series. Christian stopped by our LA studio to talk about this season's much anticipated finale, airing this Sunday night on AMC, and to tell us what it's like to work with a rotating cast of zombies on the set.


Mr. Vaglica is President and CEO of the Med Mar Group, and is responsible for the overall management of all aspects of the firm. These responsibilities include quality control, design standards, contractual obligations, proposals, negotiations, and client communication. He has nearly 20 years of experience in the construction industry and has been a project principal for the firm's industrial, commercial, and residential development infrastructure projects since the firm's founding. Mr. Vaglica is a founding faculty member of Wayne State University's College of Engineering's Construction Management Program, where he also serves as an Adjunct Professor and Program Director. Additionally, Mr. Vaglica serves on the Advisory Board at Macomb Community College. He also is a Marine Safety Officer for the Macomb County Sheriff's Department.


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A blog about the intersection of books and life.
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'In the Shadow of an Urn Commemorating Nothing'
"I wonder why I'm dead intent on adding / this to my modest box collection. I / cannot say what attracts me so to it."
I collected the usual things, nothing exotic, as a boy: coins, stamps, rocks, butterflies. I was a conventional kid and probably collected things because other kids did. It was less about greed than aesthetics. I liked and still like pretty things and things that carry an aura of context and knowledge, so I collected triangle-shaped postage stamps from Togo and learned something about that African nation. By collecting coins I learned about metals. Butterflies came equipped with a sub-collection, field guides, which I still love to read. Today I don't think of myself as a collector of books. Rather, I'm a reader, so of necessity I accumulate them. I don't buy books as an investment and don't sit staring at my shelves in admiration.
The lines at the top are from "Collecting," a poem by Edward Perlman, a writer new to me. The speaker in his poem has acquired a silver box, the sort of thing a woman might keep on her dresser or makeup table: "A pretty thing, though useless. Vain really." Decorative boxes are not to my taste but I think I understand the impulse. Their utilitarian value is small but they add a touch of gratuitous beauty to our lives. Just this week I read "Ichabod" (Yet Again, 1909), an essay in which Max Beerbohm collects something most of us don't remember, travel labels, which he places on his hat box, another once-common, now forgotten object.
"[F]ew are they who have not, at some time, come under the spell of the collecting spirit and known the joy of accumulating specimens of something or other. The instinct has its corner, surely, in every breast."
Labels are Beerbohm's madeleine dipped in tea. He renders an entire life from these "crudely coloured, crudely printed" bits of paper. Beerbohm reveled in the innately trivial, and by doing so touched on essential human themes – memory, what we value, loss:
"For many years this hat-box had been my travelling companion, and was, but a few days since, a dear record of all the big and little journeys I had made. It was much more to me than a mere receptacle for hats. It was my one collection, my collection of labels. Well! last week its lock was broken. I sent it to the trunk-makers, telling them to take the greatest care of it. It came back yesterday. The idiots, the accursed idiots! had carefully removed every label from its surface. I wrote to them—it matters not what I said. My fury has burnt itself out. I have reached the stage of craving general sympathy. So I have sat down to write, in the shadow of a tower which stands bleak, bare, prosaic, all the ivy of its years stripped from it; in the shadow of an urn commemorating nothing."
Posted by Patrick Kurp at 12:00 AM


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Santa Rita is a municipality in the Honduran department of Copán.

History
The municipality of Santa Rita is believed to have been founded in 1700, where it was then known as Aldea Cashapa. However, the area was not recognized as a municipality until 1875.
Also it has great people as well living in it.

Villages
A total of 31 villages are in Santa Rita:
 Santa Rita, which is head of the municipality
 Agua Caliente
 Buena Vista
 Campamento
 El Gobiado
 El Jaral
 El Mirador
 El Planón
 El Raizal
 El Rosario
 El Tamarindo
 Gotas de Sangre
 La Canteada
 La Casita
 La Libertad
 La Reforma
 La Unión Otuta
 Las Medias
 Las Mesas
 Los Achiotes
 Los Planes de La Brea
 Los Ranchos
 Minas de Piedras
 Mirasol
 Plan Grande
 Rastrojitos
 Río Amarillo
 Río Blanco
 San Jerónimo
 Tierra Fría No.1
 Tierra Fría No.2
 Vara de Cohete

References

Municipalities of the Copán Department

Populated places established in 1700

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