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Predisposing Factor Age (52 years old) Gender (Male) Family History of HPN and Diabetes Mellitus Precipitating Factor -Smoking (54 packed years) -Excessive Alcohol Intake (10 bottles a week) -Diet (Salty, Fatty diet) -Carbonated Drinks -Ethnic Background

Pathophysiology (ESRD)

DM II (203 mg/dl)

Carbonated drinks

Diet (Salty, Fatty diet)

Excessive alcohol intake

Smoking (54 packed years)

Hypertension

Glucose that circulates in blood

Glucose level in the blood

Accumulation of excessive fats

Level of NADH and FADH

Engulfment of fat cells in blood vessel wall

Basement membrane of glomerolus is abnormally thickened and + cell proliferation

Release of nicotine to the body

Generalized vasoconstriction

Potent vasoconstriction

Peripheral resistance

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Proton gradient

Body compensates by stimulation of immune response Macrophage engulfs fat cells

Age (52 years old)

Gender (Male)

Complex III stops further increase by stopping electron transport chain

Start of degenerative changes

Stress

Becomes foam cells Mitrochondrial production of reactive oxygen species

Loss of elasticity of blood vessels

Release of catecholamines

Embeds in vessel wall that is encapsulated to a fibrous sac

Narrowing

Vasoconstriction

Damage DNA Plaque formation Activates PARP1

ADP-Rybosylation of GAPDH (protein involved in glucose metabolism pathway

Deposition of CA to the plaque Plaques becomes hard and inflexible

Atherosclerosis

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Activates multiple pathogenic mechanisms Narrows blood vessels Unable to constrict or dilate Atherosclerotic event forms in aorta
2D Echocardiogram

Atherosclerotic Aorta

Blood flow Production of AGE products

2D Echocardiogram

Calcification of aortic annulus Glycosylation Narrowing Forms in the arterial BV

Calcification of aortic annulus

Unable to provide adequate contraction

Endothelial thickening Permeability to nitric oxide

2D Echocardiogram

Blood Volume in aorta

Ascending Aorta 3.6 cm in diameter

Dilatation of aorta

platelet and leukocyte adhesion

Contraction

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Adhesive layers thickens Pressure Transport pores became stiff and open Leakage of protein in the vasculature

Aortic valve regurgitation

2D Echocardiogram

Glucose and CHON forms an irreversible collagen like complex

Left Ventricular dilatation, Hypertrophied walls, Hypokinesia

blood volume in left ventricle

Contraction
Deposition to thickened vascular wall
2D Echocardiogram

S/Sx Murmurs Engulfs circulating molecules

Further endothelial damage Further thickening

Thickened Mitral valve leaflets

Mitral valve regurgitation

Blood from left ventricle regurgitates to left atrium

Blood volume in left atrium

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Narrowing/blockage in arterial vasculature of kidneys

Pressure in left atrium

2D Echocardiogram

Blood that travels to the kidney is decreased oxygen and nutrient supply

Contraction

Hypokinesia Blood from left atrium regurgitates to the pulmonary veins

Demand Blood travels back to the lungs

Ischemia

Renal perfusion

Diabetic Nephropathy

Xray Results Pulmonary congestion

Pulmonary congestion

GFR

Release of erythropoietin

Damage to the kidneys

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Bone marrow production and unable to maturate RBC Damage to nephrons

Damage to glomerulus
Complete Blood Count Hemoglobin 92 (140180g/L) Hematocrit 0.27(0.40-0.54) RBC 3.09 (4.0-5.4)

Glumerulosclerosis

Apoptisis of RBC Glomerular enlagement Anemia Glomerular basement membrane enlargement Proteinuria

Albumin

Stage 1 Diminished renal preserve of GFR Kidneys compensate to the damaged nephrons

S/Sx Pale Conjunctiva, Lips and Buccal mucosa, nail beds

Oncotic pressure Stimulation of SNS

Fluids leak out from interstitial space

Stimulates juxtaglomerular cells

Goes to the lungs Further in congestion

Goes to the pleural space

Edema

function of other working nephrons

Stimulates reninangiotensin axis

Pleural Effusion Accumulation to the pericardial space

S/Sx Chest Pain

Pericardial Effusion

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Normal Absorption

Angiotensinogen

Renin

Angiotensin I Normal BUN and Creatinine

ACE(angiotensin converting enzyme)

S/Sx 2mm Pitting Edema(legs, ankles, feet, arms ) Lab Examination 51mmhg pulmonary artery pressure

2D Echocardiogram

Small Pericardial effusion, pleural effusion

Angiotensin II Further work of nephrons

Damages other nephrons that are working Damages 75% of kidneys

Stresses adrenal cortical regulation

Pressure in lungs

Goes to pulmonary artery

Interference between oxygenated blood and unoxygenated blood

Hypothalamus Anterior pituitary gland Posterior pituitary gland Blood regurgitates to right side of the heart (from lungs to right ventricle) S/Sx RR=24 Dyspnea Orthopnea Crackles Productive Cough

Stage II GFR 20% 50%

Sympathetic Activity

ACTH secretion

ADH(vasopre ssin) secretion

Potent Vasoconstriction

BUN and creatinine rises

Blood volume in right ventricle

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Compensate with GFR nephrons in function Filtration of more concentrated blood of remaining nephrons Adrenal cortex Aldosterone Cortisol Na reabsorption H2O retention K excretion Potassium in the body H2O reabsorption S/Sx 2mm Pitting Edema (legs, ankles, feet) Oliguria blood pressure S/Sx BP=160/80 mmhg Pressure in right ventricle

Tricuspid valve regurgitation Blood regurgitates from right ventricle to right atrium

S/Sx Murmurs

Further work Blood Chemistry Potassium level 3.5meq/L(3.85.50meq/L) Pressure to right atrium

Hypertrophy of nephrons

Further damage

Muscle contractility

Sends the blood back to jugular veins

Further filtration Muscle weakness 80-90% damage in kidneys jugular vein pressure S/Sx 2 cm jugular vein distention (2cm) Further of edema
S/Sx 2mm Pitting Edema (legs, ankles, feet, arms )

S/Sx Fatigue

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S/Sx Oliguria

GFR 10-20%

S/Sx Anuria Blood Chemistry Creatinine 9.63mg/dl (0.481.17) Uric Acid 7.78 mg/dl (0-7.11)

Uremia

Impaired kidney function S/Sx Uremic Frost

Toxins in the blood circulates the body

Inability to excrete phosphate Phosphate reabsorption Hyperphosphatemia

Inability of kidney to activate Vitamin D3 Low levels of calcitriol

Capacity to filter anion of organic acids Retention of anion substances Anion gaps

Persistent inflammation of monocyte

Defect in the costimulatory function of APC

Results to hypocalcaemia

2ND signal of antigen is impaired Unable to proliferate and survive Impaired immune function T-cell anergy Renal osteodystrophy
Blood Chemistry

Metabolic acidosis ABG test Metabolic Acidosis

S/Sx Joint Pain

Phosphorus 5.63 mg/dl (2.61-4.35) Calcium 7.45 mg/dl (8.411.0)

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Type 1 Helper T cells response is impaired

Goes to the brain Damages/disrupt s the function of brain Uremic blood expands to intracranial space intracranial pressure S/Sx Dizziness

Infiltration of mycobacterium tuberculae

Lodges to lung periphery

Multiply in the lungs

Lipopolysaccharide present in cell wall of bacteria (exogenous pyrogens)

Bodys response

Xray Result Consider Pneumonia Left Lobe

Pneumonitis or lung inflammation

LPS binds with lipopolysaccharidebinding protein (immunological protein)

Attracts neutrophils and macrophages

LBP-LPS complex then binds to CD14 receptor of a macrophage

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Complete Blood Count WBC 50.9 (5.010.0x10^g/L)

Migration to lungs

Bacterias are being engulfed by the macrophages and neutrophils

Results in the synthesis and release of endogenous cytokine

Granulomatous lesion (tubercle)

Releasing prostaglandin E2 (PGE2)

Pus/Mucus formation

Infected tissues within tubercles die

PGE2 stimulates hypothalamus generating systemic response Causing heat creating effects

S/Sx Yellowish mucus secretions

body temperature Body compensates by changing the set point of body temperature

S/Sx Fever (39.6C) Shivering