1. Lane’s Story A Case Study in Renal Physiology: Blood Pressure Melissa Scott Mountain Brook High School 3650 Bethune Drive Birmingham, AL 35223 scottme@mtnbrook.k12.al.us

2. Lane is an active two year old with an extensive history. He was identified at 21 weeks in utero with multicyctic dysplasia. He had a left ureterostomy at 4 weeks of age; a right nephrectomy, bladder augmentation and left ureter reattachment at 18 months of age; and a bladder augmentation take- down at 28 months of age. Since the last procedure, nephrologists have carefully followed his progress. Lane- born 2/5/99 (Shown, age2)

3. Age 2 Plasma Levels Lane’s Values Normal Values Sodium140134-145 Potassium4.33.3-4.6 Chloride10398-110 Calcium10.08.7-9.8 Phosphorus6.33.8-6.5 Glucose11067-109 BUN145-17 Creatinine0.40.3-0.7 Anion Gap 95-18 CO 2 2820-30 Alkaline Phosphatase 174145-320

4. Are any of these values outside of the “normal” range? If so, propose a possible explanation.

5. Age 2 LevelsLane’s Levels Normal Values Blood Protein 5.75.9-7.0 Urine Specific Gravity 1.010 1.002 to 1.028 Urine pH7.06-8 Urine Protein PositiveNegative

6. Are any of these values outside of the “normal” range? If so, propose a possible explanation.

7. Lane’s Age Blood Pressure Normal Value for Age 2120/61 101-110/ 59-63 3113/55 104-113/ 63-67 4119/45 106-115/ 66-71 5105/62 108-116/ 69-74 6123/59 109-117/ 72-76 8119/64 111-120/ 75-80 Blood Pressure at Various Ages

8. GFR by the Schwartz formula 108 ml/min Normal GFR= about 125 ml/min Glomerular Filtration Rate Age 8

9. Using a concept map, show the relationship between decreased GFR (as in renal diseases) and increased blood pressure.

10. ↑ Renin ↑ Blood Volume ↑ Arterial Pressure ↑ Angiotensin II ↑ Aldosterone ↓ GFR Vasoconstriction ADH (Vasopressin) secretion Renal fluid and sodium reabsorption Insert the statements in the lower left in the proper prompt to show the relationship between decreased GFR and increased blood pressure.

11. Why does decreased GFR cause increased renin secretion?

12. Lisinopril at 2.5 mg daily prescribed Age 8

13. What classification of drugs does Lisinopril fall under? Explain how these drugs regulate blood pressure.

14. What activities does angiotensin II perform?

15. Blood pressure= 109/59 Normal values= 111-120/ 75-80 Proteins in urine= negative Normal values= negative 1 Month After Initiating Lisinopril Use

16. Was the use of lisinopril successful?

17. Lane- Happy and Healthy!

18. Eaton, D.C., Pooler, J.P. Vander’s Renal Physiology. Lange Medical Books/McGraw- Hill, 2004. Klatt, E. C., Urinalysis. In The Internet Pathology Laboratory for Medical Education. Retrieved July 5, 2008, from http://library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html http://library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html Klauber, G., Urology, New England Medical Center, Boston, MA. Milner, L., Nephrology, New England Medical Center, Boston, MA. Navar, L. G. Regulation of Renal Hemodynamics, Advanced Physiology Education 275:221-235, 1998. Steele, R. What is a normal blood pressure for your child? In iVillage Total Health Network. Retrieved July 5, 2008, from http://parenting.ivillage.com/tp/tphealth/0,,3qj7,00.html http://parenting.ivillage.com/tp/tphealth/0,,3qj7,00.htmlReferences

19. Are any of these values outside of the “normal” range? If so, propose a possible explanation.

20. Are any of these values outside of the “normal” range? If so, propose a possible explanation.

21. ↑ Renin ↑ Blood Volume ↑ Arterial Pressure ↑ Angiotensin II ↑ Aldosterone ↓ GFR Vasoconstriction ADH (Vasopressin) secretion Renal fluid and sodium reabsorption Insert the statements in the lower left in the proper prompt to show the relationship between decreased GFR and increased blood pressure.

22. Why does decreased GFR cause increased renin secretion?

23. What classification of drugs does Lisinopril fall under? Explain how these drugs regulate blood pressure.

24. What activities does angiotensin II perform?

25. Was the use of lisinopril successful?

26. Age 2 Plasma Levels Lane’s Values Normal Values Sodium140134-145 Potassium4.33.3-4.6 Chloride10398-110 Calcium10.08.7-9.8 Phosphorus6.33.8-6.5 Glucose11067-109 BUN145-17 Creatinine0.40.3-0.7 Anion Gap 95-18 CO 2 2820-30 Alkaline Phosphatase 174145-320

27. Are any of these values outside of the “normal” range? If so, propose a possible explanation.

28. Though some values are towards the upper limits they still fall into the “normal” ranges. The only values that are slightly high are the calcium and the glucose. Glucose was not done as a fasting glucose, so it is not accurate. The calcium is slightly high, as the phosphorus is toward the upper limits of normal (as is typical with decreased kidney function- decreased GFR).

29. Age 2 LevelsLane’s Levels Normal Values Blood Protein 5.75.9-7.0 Urine Specific Gravity 1.010 1.002 to 1.028 Urine pH7.06-8 Urine Protein PositiveNegative

30. Are any of these values outside of the “normal” range? If so, propose a possible explanation.

31. The blood proteins are slightly low. This is probably due to the loss of some protein in the urine because of the excessive pressure of glomerular blood vessels. This may force openings between the glomerular cells that perform filtration and proteins that normally cannot fit through are able to escape into the filtrate.

32. Lane’s Age Blood Pressure Normal Value for Age 2120/61 101-110/ 59-63 3113/55 104-113/ 63-67 4119/45 106-115/ 66-71 5105/62 108-116/ 69-74 6123/59 109-117/ 72-76 8119/64 111-120/ 75-80 Blood Pressure at Various Ages

33. GFR by the Schwartz formula 108 ml/min Normal GFR= 125 ml/min Glomerular Filtration Rate Age 8

34. Using a concept map, show the relationship between decreased Glomerular Filtration Rate (as in renal diseases) and increased blood pressure.

35. ↑ Renin ↑ Blood Volume ↑ Arterial Pressure ↑ Angiotensin II ↑ Aldosterone ↓ GFR Vasoconstriction ADH (Vasopressin) secretion ↑ Renal fluid and sodium reabsorption Insert the statements in the lower left in the proper prompt to show the relationship between decreased GFR and increased blood pressure.

36. ↑ Angiotensin II ADH (Vasopressin) secretion Vasoconstriction ↑ Arterial Pressure ↑ Renal fluid and sodium reabsorption ↑ Blood Volume ↓ GFR ↑ Renin ↑ Aldosterone

37. Why does decreased GFR cause increased renin secretion?

38. Damage to the kidney decreases the GFR and therefore the filtered load of sodium. Sodium retention causes increased water retention (to maintain proper oncotic balance). Macula densa cells sense decreased sodium chloride leaving the thick ascending limb (they shrink due osmotic pressure) and cause continued release of renin. (Swelling of the macula densa cells releases a renin inhibitor.)

39. Lisinopril at 2.5 mg daily prescribed Age 8

40. What classification of drugs does Lisinopril fall under? Explain how these drugs regulate blood pressure.

41. Lisinopril is an ACE (angiotensin- converting enzyme) inhibitor. ACE is an enzyme that converts angiotensin I to angiotensin II.

42. What activities does angiotensin II perform?

43. http://en.wikipedia.org/wiki/Image:Renin-angiotensin-aldosterone_system.png

44. Was the use of lisinopril successful?

45. Yes. The blood pressure has decreased. This has decreased the pressure in the glomerular capillaries and reduced the forced filtration of proteins into the urine.