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By: B. Dennis, M.A., Ph.D.

Medical Instructor, University of Houston

The tubular portion of juxtamedullary nephrons is supplied by some specialized capillaries called vasa recta symptoms precede an illness discount 25 mg capoten free shipping. Vasa recta arise directly from the efferent arteriole of the juxtamedullary nephrons and run parallel to the renal tubule into the medulla and ascend up towards the cortex 911 treatment buy capoten. Venous System Peritubular capillaries and vasa recta drain into the venous system medications zithromax discount capoten online master card. Venous system starts with peritubular venules and continues as interlobular veins medications vs medicine discount 25mg capoten, arcuate veins, interlobar veins, segmental veins and finally the renal vein. The nerves innervating renal blood vessels do not have any significant role in this. Autoregulation is present in some vital organs in the body such as brain, heart and kidneys. Blood flow to kidneys remains normal even when the mean arterial blood pressure vary widely between 60 mm Hg and 180 mm Hg. Myogenic Response Whenever the blood flow to kidneys increases, it stretches the elastic wall of the afferent arteriole. Stretching of the vessel wall increases the flow of calcium ions from extracellular fluid into the cells. The influx of calcium ions leads to the contraction of smooth muscles in afferent arteriole, which causes constriction of afferent arteriole. Kidneys are the second organs to receive maximum blood flow, the first organ being the liver, which receives 1,500 mL per minute. Whole amount of blood, which flows to kidney has to pass through the glomerular capillaries before entering the venous system. Renal glomerular capillaries form high pressure bed with a pressure of 60 mm Hg to 70 mm Hg. It is much greater than the capillary pressure elsewhere in the body, which is only about 25 mm Hg to 30 mm Hg. High pressure is maintained in the glomerular capillaries because the diameter of afferent arteriole is more than that of efferent arteriole. Peritubular capillaries form a low pressure bed with a pressure of 8 mm Hg to 10 mm Hg. Processes of Urine Formation When blood passes through glomerular capillaries, the plasma is filtered into the Bowman capsule. While passing through the tubule, the filtrate undergoes various changes both in quality and in quantity. Many wanted substances like glucose, amino acids, water and electrolytes are reabsorbed from the tubules. And, some unwanted substances are secreted into the tubule from peritubular blood vessels. Thus, the urine formation includes three processes: 316 Section 5 t Renal Physiology and Skin 2. Basement membrane Basement membrane of glomerular capillaries and the basement membrane of visceral layer of Bowman capsule fuse together. The fused basement membrane separates the endothelium of glomerular capillary and the epithelium of visceral layer of Bowman capsule. Visceral layer of Bowman capsule this layer is formed by a single layer of flattened epi thelial cells resting on a basement membrane. Each cell is connected with the basement membrane by cytoplasmic extensions called pedicles or feet. When blood passes through glomerular capillaries, the plasma is filtered into the Bowman capsule. Ultrafiltration Glomerular filtration is called ultrafiltration because even the minute particles are filtered. The protein molecules are larger than the slit pores present in the endothelium of capillaries. Thus, the glomerular filtrate contains all the substances present in plasma except the plasma proteins. This technique involves insertion of a micropipette into the Bowman capsule and aspiration of filtrate.

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Vestibular Membrane Vestibular membrane is also known as Reissner membrane and it is a thin membrane medicine misuse definition generic capoten 25mg with mastercard. It is placed obliquely between the upper surface of osseous spiral lamina and upper part of spiral ligament 10 medications that cause memory loss purchase genuine capoten on-line. Basilar membrane and vestibular membrane divide the spiral canal of cochlea into three compartments called scalae symptoms crohns disease purchase 25 mg capoten with visa. Sense organ for hearing is the cochlea and the sense organ for equilibrium is the vestibular apparatus symptoms zinc deficiency buy capoten 25 mg low price. In man, the bony canal makes two and a half turns, starting from the base of the cochlea and ends at the top (apex) of cochlea. Base of modiolus forms the bottom of internal auditory meatus, through which cochlear nerve fibers pass and enter the modiolus. Thus, a section through the axis of cochlea reveals the central bony pillar, modiolus and periotic or osseous canal, which coils around the modiolus. From modiolus, a bony ridge called osseous spiral lamina projects into the canal, winding around modiolus like the thread of a screw. Spiral lamina follows the spiral turns of cochlea and ends at the cupula in a hookshaped process called hamulus. It stretches from the tip of the osseous spiral lamina to tough dense fibrous band called spiral ligament, which lines the outer wall of the canal. At the apex, it communicates with the scala tympani through a small canal called helicotrema. Round window is closed by a strong thin membrane known as secondary tympanic membrane. Scala media Scala media is otherwise called cochlear duct, membranous cochlea or otic cochlea. A slender ductus reuniens arises from the basal end and connects scala media with the saccule of otolith organ. It is formed by basilar membrane (membranous spiral lamina) and a part of osseous spiral lamina. Scala media stretches between the tip of osseous spiral lamina and spiral ligament. Basilar membrane consists of straight unbranched connective tissue fibers, which are called basilar fibers or the auditory fibers. On the upper surface of the basilar membrane, epithelial cells are arranged in the form a special structure called the organ of Corti. Situation and Extent Organ of corti rests upon the lip of osseous spiral lamina and basilar membrane. It extends throughout the cochlear duct, except for a short distance on either end. Border Cells Border cells are the slender columnar cells, arranged in a single layer on the tympanic lip along the inner side of inner hair cells. Inner Hair Cells Inner hair cells are flaskshaped cells and are broader than the outer hair cells. Inner hair cells are arranged in a single row and occupy only the upper part of epithelial layer. Rounded base of each cell rests on the adjacent supporting cells called the inner phalangeal cell. Surface of the inner hair cell bears a cuticular plate and a number of short stiff hairs, which are called stereocilia. Both inner hair cells and outer hair cells have afferent and efferent nerve fibers (Chapter 173). Inner Phalangeal Cells Inner phalangeal cells are the supporting cells of inner hair cells and are arranged in a row along the inner surface of inner pillar cells. Cuticular plate of cells (formed by the lower portion of cells) look like the finger bones, phalanges. Each pillar cell has a broader base, an elongated body Structure Organ of Corti is made up of sensory elements called hair cells and various supporting cells. Bases of inner pillar cells are close to the lip of osseous spiral lamina (tympanic lip), whereas the bases of outer pillar cells are close to basilar membrane.

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By preventing the recycling of bile acids 300 medications for nclex cheap 25mg capoten free shipping, bile acid-binding resins divert hepatic cholesterol to synthesis of new bile acids medicine checker order capoten us, thereby reducing the amount of cholesterol in a tightly regulated pool medicine reminder alarm discount capoten 25 mg with visa. They have also been used to reduce pruritus in patients with cholestasis and bile salt accumulation symptoms torn rotator cuff order capoten 25mg overnight delivery. Toxicity Adverse effects from resins include bloating, constipation, and an unpleasant gritty taste. Absorption of vitamins (eg, vitamin K, dietary folates) and drugs (eg, thiazide diuretics, warfarin, pravastatin, fluvastatin) is impaired by the resins. Large clinical trials have shown that they reduce the risk of coronary events and mortality in patients with ischemic heart disease, and they also reduce the risk of ischemic stroke. Toxicity Mild elevations of serum aminotransferases are common but are not often associated with hepatic damage. Mechanism and Effects Ezetimibe is a prodrug that is converted in the liver to the active glucuronide form. This active metabolite inhibits a transporter that mediates gastrointestinal uptake of cholesterol and phytosterols (plant sterols that normally enter gastrointestinal epithelial cell but then are immediately transported back into the intestinal lumen). By preventing absorption of dietary cholesterol and cholesterol that is excreted in bile, ezetimibe reduces the cholesterol in the tightly regulated hepatic pool. Clinical Use Ezetimibe is used for treatment of hypercholesterolemia and phytosterolemia, a rare genetic disorder that results from impaired export of phytosterols. Serum concentrations of the glucuronide form are increased by fibrates and reduced by cholestyramine. Severe liver dysfunction has been associated with an extended-release preparation, which is not the same as the sustained-release formulation. Hyperuricemia occurs in about 20% of patients, and carbohydrate tolerance may be moderately impaired. Clinical Use Gemfibrozil and other fibrates are used to treat hypertriglyceridemia. Toxicity Nausea is the most common adverse effect with all members of the fibric acid derivatives subgroup. A few patients show decreases in white blood count or hematocrit, and these drugs can potentiate the action of anticoagulants. There is an increased risk of cholesterol gallstones; these drugs should be used with caution in patients with a history of cholelithiasis. When used in combination with reductase inhibitors, the fibrates significantly increase the risk of myopathy. In adipose tissue, niacin appears to activate a signaling pathway that reduces hormone-sensitive lipase activity and thus decreases plasma fatty acid and triglyceride levels. Finally, niacin decreases circulating fibrinogen and increases tissue plasminogen activator. The combination of reductase inhibitors with either fibrates or niacin increases the risk of myopathy. If this patient is pregnant, which of the following drugs should be avoided because of a risk of harming the fetus This patient recently experienced mild chest pain when walking upstairs and has been diagnosed as having angina of effort. Consumption of alcohol is associated with which of the following changes in serum lipid concentrations An adverse effect is that it can cause accumulation of triglycerides in the liver and elevations in transaminases. Mipomersen is an antisense oligonucleotide that targets apoB100, mainly in the liver. At his checkup, the pediatrician notices cutaneous xanthomas and orders a lipid panel.

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The administration of a 1-mg test dose of amphotericin B is sometimes useful in predicting the severity of infusion-related toxicity symptoms high blood pressure cheap capoten 25mg without a prescription. In the case of opportunistic candidal infections in the immunocompromised patient treatment nerve damage order 25mg capoten with visa, no prophylactic drugs have been shown to be clinically effective treatment renal cell carcinoma order capoten online pills. However symptoms urinary tract infection cheap capoten 25mg without prescription, prophylactic use of azoles may contribute to the development of fungal resistance. If this patient has a fungal infection of the lungs, it is probably due to C immitis, which is endemic in dry regions of the western United States. Pulmonary symptoms of coccidioidomycosis are usually self-limiting, and drug therapy is not commonly required in an otherwise healthy patient. No organisms are present in the lesions, and it is not a sign of disseminated disease. In progressive or disseminated forms of coccidioidomycosis, systemic antifungal drug treatment is needed. Until recently, amphotericin B was the recommended therapy, but fluconazole or itraconazole are now generally preferred. Note that the risk of dissemination is much greater in African Americans (10% incidence) and in pregnant women during the third trimester. Griseofulvin has no activity against C albicans and is not effective in the treatment of systemic or superficial infections caused by such organisms. Ketoconazole was the first oral azole introduced into clinical use, but it has a greater propensity to inhibit human cytochrome P450 enzymes than other azoles and is no longer widely used in the United States. Cardiotoxicity may occur when ketoconazole is used by patients taking astemizole or terfenadine as a result of the ability of ketoconazole to inhibit their metabolism via hepatic cytochromes P450. Liposomal formulations of amphotericin B result in decreased accumulation of the drug in tissues, including the kidney. Lipid formulations do not have a wider antifungal spectrum; their daily cost ranges from 10 to 40 times more than the conventional formulation of amphotericin B. A sampling of commonly used drugs with cytochrome P450-mediated metabolism inhibited by ketoconazole (and to a much lesser extent by other azoles) includes chlordiazepoxide, cisapride, cyclosporine, didanosine, fluoxetine, loratadine, lovastatin, methadone, nifedipine, phenytoin, quinidine, tacrolimus, theophylline, verapamil, warfarin, zidovudine, and zolpidem. Identify the clinical uses of amphotericin B, flucytosine, individual azoles, caspofungin, griseofulvin, and terbinafine. The selective toxicity of antiviral drugs usually depends on greater susceptibility of viral enzymes to their inhibitory actions than host cell enzymes. This can result in greater clinical effectiveness in viral infections and can also prevent, or delay, the emergence of resistance. The drug is activated to form acyclovir triphosphate, which interferes with viral synthesis in 2 ways. Note: interferon-alfas are speculated to have multiple sites of action on viral replication. Pharmacokinetics-Acyclovir can be administered by the topical, oral, and intravenous routes. Because of its short half-life, oral administration requires multiple daily doses of acyclovir. Renal excretion is the major route of elimination of acyclovir, and dosage should be reduced in patients with renal impairment. Toxic effects with parenteral administration include delirium, tremor, seizures, hypotension, and nephrotoxicity. Famciclovir is a prodrug converted to penciclovir by first-pass metabolism in the liver. Because phosphorylation does not require viral kinase, cidofovir is active against many acyclovir and ganciclovirresistant strains. Dosage should be adjusted in proportion to creatinine clearance and full hydration maintained. Nephrotoxicity is the major dose-limiting toxicity of cidofovir, additive with other nephrotoxic drugs including amphotericin B and aminoglycoside antibiotics.

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