Nephrology Knowledge Base

Kidney Physiology and Biophysics
Thursday, February 2, 2023 1:36 PM
Background
The kidneys are two bean-shaped organs located below the ribcage in the retroperitoneal space. Each kidney is
roughly the size of a fist, about 10-12 cm tall and 5-7 cm wide with a weight of approximately 150 to 200
grams in males and 120 to 135 grams in females [1]. The kidneys are oriented on either side of the spine, with
the right kidney oftentimes positioned slightly lower than the left due to the stomach and liver offsetting the
symmetry of the abdomen [2].
The main functions of the kidney are to control blood pressure, stabilize water levels, remove toxins, and
regulate acid-base balance in the blood [2]. The human body maintains approximately five (5) liters of blood in
circulation at any time. Receiving 20-25% of the hearts output, on average, the kidneys filter approximately 190
liters of blood and produce approximately 1-2 liters of urine each day.
Nephrology - Kidney Physiology Overview
Renal Physiology Nephrology and Urology
The study of the physiology of the kidney, renal physiology, is the study of all the functions, responsibilities, Nephrology, a subset of internal
and processes of the kidney. medicine, is the study, care, and
treatment of various disease that
Homeostasis may occur in the kidney.
The kidney plays a critical role in the maintenance of chemical homeostasis, or chemical equilibrium, in the Urologists, a subset of surgical
medicine, oftentimes focus more
body; responsible for the balance of electrolytes. In addition to these chemicals, the kidneys (along with the
lungs) are responsible for the pH, or acid-base balance, of the body. The kidneys do this by reabsorbing on the broader urinary tract, and
treat diseases throughout.
bicarbonate from urine and excreting hydrogen ions into urine. [3]
Figure 1. The position of the kidneys in the human body and their main components.
Sources
[1] Anatomy, abdomen and pelvis, kidneys - statpearls - NCBI bookshelf. (n.d.). Retrieved February 2, 2023, from
Kidney Physiology and Biophysics Page 2

https://www.ncbi.nlm.nih.gov/books/NBK482385/
[2] MD, J. V. (2022, December 28). Kidneys. Kenhub. Retrieved February 2, 2023, from
https://www.kenhub.com/en/library/anatomy/kidneys
[3] https://med.libretexts.org/Bookshelves/Anatomy_and_Physiology/Book%3A_Anatomy_and_Physiology_(Boundless)/25%
3A_Body_Fluids_and_Acid-Base_Balance/25.4%3A_Acid-Base_Balance/25.4D%3A_The_Role_of_the_Kidneys_in_Acid-
Base_Balance#:~:text=The%20kidneys%20have%20two%20very%20important%20roles%20in,urine.%202%20They%20excrete%
20hydrogen%20ions%20into%20urine.
Acknowledgements
We would like to acknowledge and thank Dr. Luis Sanchez-Russo, a fourth-year nephrology fellow at Mount Sinai, for the tremendous
help, guidance, and input given to us in order to improve our wiki.

Structure
Renal System
The kidney is made up of three (3) main regions: the renal cortex, renal medulla, and renal pelvis.
The renal cortex is made up of granular tissue surrounds the kidney contains blood vessels and
nephrons [1].
The renal medulla, beneath the renal cortex, is made up of renal pyramids and contains the
structure of the nephrons.
The renal pelvis connects the structures of the kidneys to the ureter and allows for urine to be
removed from the system.
Circulatory System and Blood Supply

The kidneys mainly connect to the circulatory system though the renal arteries, which supply blood
from the aorta to the kidneys; and the renal vein, outputting the filtered blood from the kidneys back to
the heart via the inferior vena cava. Each kidney connects to the rest of the renal system via the ureter,
which carries urine from the kidneys to the bladder.
Nervous System
The kidneys connect to the nervous system via the nerves that make up the renal plexus, a complex
system of afferent (sensory signals) and efferent (motor signals) nerves that compose the connection
between the nervous system and brain, with the renal system and kidneys. These nerves, as part of the
sympathetic nervous system responsible for threat and stress response, contribute to the kidney's ability
to regulate systemic blood pressure by sending input signals to stimulate the Beta-1-adrenergic receptors in
the cells of the kidney [2].
Figure 2. Kidney labeled with its components.
Nephrons
The kidneys contain approximately 2 million nephrons, the functional unit of the kidney responsible for
filtering blood. Each nephron includes a filter, called the glomerulus, and a system of tubules. The
nephrons work through a two-step process: the glomerulus filters your blood, while the tubules returns
needed
Sources
substances to your blood via reabsorption, and removes waste in the form of urine.
[1] Libretexts. (2023, January 17). 24.2b: Internal Anatomy of the kidneys. Medicine LibreTexts. Retrieved February 2, 2023, from https://med.libretexts.org/Bookshelves/Anatomy_and_Physiology/Book%
3A_Anatomy_and_Physiology_(Boundless)/24%3A__Urinary_System/24.2%3A_The_Kidneys/24.2B%3A_Internal_Anatomy_of_the_Kidneys
[2] Anatomy, Abdomen and Pelvis, Kidney Nerves - StatPearls - NCBI Bookshelf (nih.gov)

Function
filtration. Filtering takes place in the nephrons, of which there are around two million per adult kidney. In
each nephron, blood is brought in through afferent arterioles. Blood cycles through each nephron through the
glomerulus, which is a network of small capillaries where glomerular filtration takes place [1].
Glomerular Filtration
Glomerular filtration is a passive process that is driven by pressure. The main pressure force is supplied by
hydrostatic pressure in the glomerular capillaries, in which around 55mmHg of pressure forces blood through
a filtration membrane. As the blood travels through the glomerulus, water and solutes are filtered out, which
results in the glomerular filtrate that will eventually become urine [2].
important nutrients are reabsorbed into the bloodstream. The proximal tubule, for example, is one of the
tubular segments that help reabsorb water and salt. By the end of the process, over 99% of water, salt, and
other filtrates are absorbed back into the body. Water is absorbed through osmosis, and salt is absorbed via
concentration gradient [2].
Besides reabsorption, the tubules also aid in eliminating harmful substances such as drugs, ammonias,
organic acids, and bases through a process known as secretion. Secretion helps to control the pH of blood by
removing hydrogen ions [2].
Excretion
The final step is excretion, in which the filtrate, now urine, exits the kidney through the ureter. In normal
circumstances, humans produce 1.5 liters of urine per day after filtering around 190 liters of blood. This can
be estimated by calculating the GFR, or glomerular filtration rate, which is normally around 120 milliliters
per minute [2]. The kidney also maintains blood pressure and secretes important hormones such as vitamin
D, renin, and erythropoietin [4,5].

Figure 3: Simplified diagram of the pathway of filtration in the nephrons. [3]
Sources
[1] Anatomy, abdomen and pelvis, kidneys - statpearls - NCBI bookshelf. (n.d.). Retrieved February 2, 2023, from
[2]Physiology, renal - statpearls - NCBI bookshelf. (n.d.). Retrieved February 2, 2023, from
[3] NIDDK. (2018, June). Your kidneys & how they work. National Institute of Diabetes and Digestive and Kidney Diseases.
Retrieved February 2, 2023, from https://www.niddk.nih.gov/health-information/kidney-disease/kidneys-how-they-work
[4] Van Beusecum, J., & Inscho, E. W. (2015, April). Regulation of renal function and blood pressure control by P2
purinoceptors in the kidney. Current opinion in pharmacology. Retrieved February 2, 2023, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5515225/
[5] Sahay, M., Kalra, S., & Bandgar, T. (2012, March). Renal endocrinology: The New Frontier. Indian journal of endocrinology
and metabolism. Retrieved February 2, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3313729/

Kidney Disease
Acute Kidney Injury

Acute kidney injury (AKI) is defined by a sudden decline in glomerular filtration rate
(GFR) that results in elevated serum creatinine, blood urea nitrogen, and electrolyte levels
[1]. AKI is caused by kidney ischemia from impairment in blood flow, nephrotoxins from
toxic medications and chemicals, dehydration or sepsis [2,3]. Certain causes of AKI are
linked to pathophysiological processes, or processes related to abnormal changes in body
functions linked to disease processes, that consist of changes in gene expression patterns
[2]. Studying the mechanisms associated with the structural or functional damage of the
kidney provides insight into the prevention, diagnosis, and treatment of AKI.
Chronic Kidney Disease
Chronic kidney disease (CKD), which occurs when the kidneys are damaged and cannot
properly filter blood, was found to be a major risk factor in the development of AKI [4].
Patients with CKD who develop AKI have an increased risk of kidney failure and
mortality, and patients who survive AKI with pre-existing CKD are more likely to develop
cardiovascular disease and progressive CKD than patients without it [5].
Figure 4. Statistics provided by the CDC show
Click here to learn more about Living with CKD that an estimated 15% of US adults suffer from
Click here to learn more about Types of CKD chronic kidney disease.
Sources
[1] MD;, R. M. H. O. (n.d.). Acute kidney injury associated with cardiac surgery. Clinical journal of the American Society of Nephrology : CJASN. Retrieved February 2,
2023, from https://pubmed.ncbi.nlm.nih.gov/17699187/
[2] Scholz, H., Boivin, F. J., Schmidt-Ott, K. M., Bachmann, S., Eckardt, K.-U., Scholl, U. I., & Persson, P. B. (2021, February 5). Kidney Physiology and susceptibility to
acute kidney injury: Implications for renoprotection. Nature News. Retrieved February 2, 2023, from https://www.nature.com/articles/s41581-021-00394-7
[3] Al-Naimi, M. S., Rasheed, H. A., Hussien, N. R., Al-Kuraishy, H. M., & Al-Gareeb, A. I. (2019). Nephrotoxicity: Role and significance of renal biomarkers in the early
detection of acute renal injury. Journal of advanced pharmaceutical technology & research. Retrieved February 2, 2023, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6621352/#:~:text=Nephrotoxicity%20is%20defining%20as%20rapid,Nephrotoxins%20are%20substances%20displaying%
20nephrotoxicity
[4] Ferenbach, D. A., & Bonventre, J. V. (2016, April). Acute kidney injury and chronic kidney disease: From the laboratory to the Clinic. Nephrologie & therapeutique.
Retrieved February 2, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5475438/
[5] Wald R;Quinn RR;Luo J;Li P;Scales DC;Mamdani MM;Ray JG; ; (n.d.). Chronic dialysis and death among survivors of acute kidney injury requiring dialysis. JAMA.
Retrieved February 2, 2023, from https://pubmed.ncbi.nlm.nih.gov/19755696/

Dialysis
Dialysis, a process that removes waste and impurities from the blood, is necessary to treat kidney failure
or end-stage kidney disease (ESKD) when CKD or AKI prevents the kidney from properly performing
its functions [1]. There are two main types of dialysis: hemodialysis and peritoneal dialysis.
Hemodialysis
[2]. The blood is pumped through the filter and returns to the body as shown in Figure 5. During the
filtration process, the dialysis machine regulates the rate at which blood flows through the filter and fluid
is removed from the body [2].
Figure 5. During hemodialysis, blood is pumped through a dialyzer [2].
Peritoneal Dialysis
and dialysis solution, which absorbs waste from the body, flows into the belly through the catheter.
Click Here to Learn More about Low-Cost Dialysis Options

Click Here to Learn More about Dialysis Options Worldwide
Click Here to Learn More about Hemodialysis and Peritineal Dialysis
Sources

[1] Dialysis - hemodialysis. Mount Sinai Health System. (n.d.). Retrieved February 2, 2023, from
https://www.mountsinai.org/health-library/special-topic/dialysis-hemodialysis
[2] U.S. Department of Health and Human Services. (n.d.). Hemodialysis. National Institute of Diabetes and Digestive and
Kidney Diseases. Retrieved February 2, 2023, from https://www.niddk.nih.gov/health-information/kidney-disease/kidney-
failure/hemodialysis
[3] U.S. Department of Health and Human Services. (n.d.). Peritoneal dialysis. National Institute of Diabetes and Digestive and
Kidney Diseases. Retrieved February 2, 2023, from https://www.niddk.nih.gov/health-information/kidney-disease/kidney-
failure/peritoneal-dialysis

Hemodialysis and Peritoneal Dialysis
Thursday, March 30, 2023 1:10 PM
Hemodialysis
Peritoneal Dialysis
71% with end-stage renal disease (ESRD) are on hemodialysis (500,000)
29% have a kidney transplant (wait-time is around 4 years) Removes waste product from lungs when kidney(s) fail
Around 20,000 per year Cleansing fluid flows through a catheter into part of your abdomen. Abdomen lining
12.5% is performed at home (peritoneum) acts as a filter and removes waste products from your blood. After a
Death is greater for patients who undergo hemodialysis rather than kidney transplant set period of time, the fluid with the filtered waste products flows out of your
160 per 1,000 opposed to 49 per 1,000 abdomen and is discarded.
A machine filters wastes, salts and fluid from your blood when your kidneys are no Can be done from home
longer healthy enough to do this work adequately More lifestyle flexibility
Serious responsibility (can be done at home) Less common than hemodialysis
Possible side effects: "Adjusted mortality decreased by nearly 15% in patients receiving hemodialysis and
Hypertension (low blood pressure) by nearly 20% in patients receiving peritoneal dialysis between 2009 and 2018."
Diet change: limiting alcohol and smoking
Diet rich in fruits, vegetables, fish, nuts, legumes
Muscle cramps
Anemia (not enough red blood cells)
Center: 3x weekly (3-4 hours)
Home: daily (2 hours)
How Hemodialysis Works

Peritoneal Dialysis Process at Home with Willie
<-- Catheter Placement
Living With CKD Page 10

Living With Kidney Disease
Lifestyle/Daily Life
Regular hemodialysis treatments: A person undergoing hemodialysis typically

receives treatment three times a week, with each treatment lasting about 4 hours.
Monitoring of fluid and dietary intake: People undergoing hemodialysis need to
closely monitor their fluid intake in order to avoid fluid overload, which can cause
dangerous complications. They may also need to follow a special diet that is low in
potassium, phosphorus, and sodium in order to help the kidneys function more
effectively.
Medications: People with chronic kidney disease or kidney failure may need to take
medications to control symptoms, such as high blood pressure (enalapril, lisinopril),
anemia (erythropoietin, a hormone normally produced by the kidneys), and bone
disease.
Monitoring of health: People undergoing hemodialysis may need to regularly check
their blood pressure and monitor for signs of infection at injection points or other
complications.
Lifestyle adjustments: Patients may need to avoid alcohol, tobacco, and certain
medications that can be harmful to the kidneys. They may also need to be more
mindful of their overall health, such as by getting enough sleep, eating a healthy diet,
and getting regular exercise.
Traveling with hemodialysis can be challenging, patients may have to plan ahead to
find dialysis centers along their route and schedule treatment around their travels.
"Living With Kidney Disease" CityNews, Canada

Diet
Diet
One of the main ways it does this is by limiting the amount of certain nutrients that a
person can consume.
People on hemodialysis may need to limit their intake of potassium, phosphorus
(processed meat, bread, beer, chocolate), meat and fluid.
Patients on hemodialysis may also need to consume more protein and calories to
help maintain their weight and muscle mass.
Some patients may also be advised to avoid foods high in sodium as it can cause
high blood pressure.
Eat less salt because it builds up in the body when kidneys are failing
A dietitian or a nephrologist would advise the patient accordingly on what to eat and
what to avoid.
Diabetes is the most common cause of kidney failure, in which the kidneys no longer
function
risk of kidney failure can be decreased by controlling diabetes
It is important for patients on hemodialysis to stick to a healthy and well-balanced
diet to help maintain their overall health and well-being.

Risks Associated with Kidney Disease
Compounding Risks Associated with Kidney Disease

Affects more than 1 in 7 US adults (37 million)
A leading cause of death in the US
Having CKD increases the chances of a patient developing heart disease and having a stroke.
Health Problems Due to Low Kidney Function:
Anemia or low red blood cell count, which can cause fatigue and weakness.
Extra fluid in the body, which can cause high blood pressure, swelling in the legs, or shortness of breath.
A weakened immune system, which makes it easier to develop infections.
Loss of appetite or nausea.
Decreased sexual response.
Confusion, problems with memory and thinking, or depression.
Low calcium levels and high phosphorus levels in the blood, which can cause bone disease and heart disease.
High potassium levels in the blood, which can cause an irregular or abnormal heartbeat and lead to death.

WORKS CITED!!
Works Cited:
Www.cdc.gov, 10 Mar. 2021,

www.cdc.gov/kidneydisease/publications-resources/annual-report/ckd-related-
health-problems.html.
- Diagnosis and Treatment - Mayoclinic.org,

2017, www.mayoclinic.org/diseases-conditions/anemia/diagnosis-
treatment/drc-20351366.
- Mayoclinic.org, 2019,
www.mayoclinic.org/tests-procedures/peritoneal-dialysis/about/pac-20384725.
Www.heart.org,
31 Oct. 2017, www.heart.org/en/health-topics/high-blood-pressure/changes-you-
can-make-to-manage-high-blood-pressure/types-of-blood-pressure-medications
- Mayoclinic.org, 2018,
www.mayoclinic.org/tests-procedures/hemodialysis/about/pac-20384824.
Nyulangone.org,
nyulangone.org/conditions/kidney-disease/treatments/lifestyle-changes-for-kidney-
disease
Kidney Disease Statistics for the United States | NIDDK (nih.gov)

All Pictures From Creative Commons

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Notes and Feedback Ayushi, Tre, Joon
(no notes were implemented)
Wednesday, May 10, 2023 10:51 PM
Name of Specialist: Madhu Vijayan

Date: Feb 25, 2023
OVERALL
Better note on the wide range of kidney issues
More focus on kidney replacement therapies
transplant greatly increases quality of life for many patients (less medicines, visits, etc.)
Add more info in general
ORDER/ORGANIZATION:
Diet and lifestyle first
Add living with a kidney transplant section
Put info in order of disease stage (1-5)
DIET:
Diet recommendations for early stage kidney disease
Increased nut intake
Reduce general fluid intake (because of fluid accumulation)
Take extra proteins and calories BECAUSE the dialysis machine can remove some needed nutrients
Focus diet section on hypotension recommendations
Add a point about handling high blood pressure to reduce risk of disease
SOURCES:
Add in-text citations
National Kidney Foundation
Information on diet for early stage
United States Renal Data System (USRDS)
Use five-year survival rate
Patient
education...
LIFESTYLE:
Note WHY the specialized diet
Reduce potassium BECAUSE kidneys not working, not to keep them health - it prevents complications
Include lifestyle information for peritoneal (at home) treatment - not just hemodialysis
GRAMMAR:
Expand acronym in first use CKD

Hyper/hypo tension - fix that to typo
Can cause swelling
PERETONEAL DIALYSIS:
More general info on how it works
and what lifestyle changes occur
about keeping access points clean
Peritonitis (infection)
Symptoms and notes on infection
Length - 12hrs usually while sleeping
Manually cycling vs using a cycler
CATERING TO ENGINEERS:
The artificial kidney project
Kidney x Accelerator project
Talk about upcoming projects and how they could change patient outcomes

History of Racial Coefficients in eGFR Equations
In the development of equations used to estimate glomerular filtration rates, race and ethnicity
has been used as a biological variable. Different factors have led to medical bias and shifts in
the standards at which people are classified. There is debate regarding whether the elimination
of the racial coefficients in eGFR equations would improve, worsen, or have no effect toward
these standards at which people are diagnosed.
Racial Coefficients Improving Nephrological Care
When investigating whether eliminating the racial coefficients in eGFR equations would
improve or worsen standards at which patients are diagnosed, different sources suggest the
racial coefficient has improved care in identifying kidney disease. According to Medical News
Today, the eGFR equations take into account race, sex, and age which only improves
evaluating kidney function. (16) Two common equations used are the Modification of Diet in
Renal Disease (MDRD) equation and the Chronic Kidney Disease Epidemiology Collaboration
(CKD-EPI) equation. Contrastingly, these equations were found to overestimate GFR values in
African-Americans.
Racial Coefficients Deteriorating Nephrological Care
Chronic Kidney Disease Epidemiology Collaboration
In a study performed by the National Health and Nutrition Examination Survey from
2015 to 2018, GFR values were calculated with and without the race specific
coefficients used in these equations. The Chronic Kidney Disease Epidemiology
Collaboration (CKD-EPI) equation uses a racial coefficient of 1.159 if patient is identified
as Black. According to the US NHANES study, elimination of the racial coefficients
suggest that more Black people would be diagnosed with chronic kidney disease and
referred to nephrological care. (9)
Modification of Diet in Renal Disease
The Modification of Diet in Renal Disease (MDRD) is an equation used by most health
institutions that uses a racial coefficient of 1.21. When investigating how the MDRD
equation was developed, different factors were ignored. For example, Black
participants who were apart of the development of the equation, experienced excess
diabetes, hypertension, and poverty. According to the US NHANES, 10.4% more Black
Americans would be diagnosed with a threshold for Stage 3 CKD. Overall, removal of
the race coefficient in this equation would increase the percentage of Black people
diagnosed with CKD, referred to specialty care, and referred for a kidney transplant.
Consequently, the study found that both racial coefficients systemically disadvantage Black
Racial disparities in nephrological care Page 18

patients as the racial coefficients create inaccurate and unscientific practices. Eliminating
these coefficients overall, would deconstruct bias and open opportunity to more
unprejudiced medicine. Moreover, it was concluded that these racial coefficients only create
harmful effects in medicine that place Black patients seeking nephrological care at an unfair
disadvantage. As suggested by the US NHANES, the American Society of Nephrology and the
American Kidney Foundation have developed a new race-free eGFR equation that is solely
creatinine based, compared to the creatine based equations that have included race as a
factor. Furthermore, creatinine based equations that eliminate race as a factor were found to
be more accurate. (19) The creatinine based equations that removed race as a factor helped
close disparities between Black and non-Black participants.
As of 2021, many medical institutions have eliminated the racial coefficient for Black patients
due to disparities in kidney care. More specifically, when it is in relation to access to a kidney
transplant and receiving specialty care. Racial disparities in nephrological care are rooted
deeper than the racial coefficients involved in the GFR equations. Defining chronic kidney
disease as a "socioeconomic deprivation" would be an understatement. Tracing back to a
lack of access to proper health care and facing further racial discrimination within medical
care, these all create significant inequities in nephrological care. Moreover, when analyzing
different studies, race should be a factor in assessing treatment modalities in order to
dispute the systemic disadvantages that have been established.

Disparity in Impact and Treatment of Kidney Disease
HOW RACE/SOCIOECONMIC STATUS CONTRIBUTES TO HEALTH
Minority populations have much higher rates of high blood pressure, diabetes, obesity
and heart disease, all of which increase the risk for kidney disease.(2)
Race and ethnicity are socio-political constructs that are inextricably tied to health
outcomes for individuals from racial and ethnic minority groups worldwide.(12)
Lack of access to healthy food sources, stress due to discrimination and work are all
contributing factors to chronic diseases that increase the risk of kidney diseases.(2)
Individuals from marginalized racial and ethnic communities have a significantly higher
risk of kidney failure. Specifically, the risk of developing kidney failure that requires
dialysis or kidney transplantation is 2.6-fold higher in Black individuals and 1.5-fold higher
in Hispanic individuals than in white individuals.(3)
DISPARITY IN TREATMENTS RECIEVED
Black people have lower access to kidney transplants than white people do and lower access to
end-stage treatment(1)
Black people are more likely to receive prolonged dialysis care which usually leads to fatal
complications (2)
White people are 3x more likely to get a living kidney donor
Black and Hispanic patients were younger and less likely to have private insurance than Asian and
white parents which pushes the notion that CKD is associated with socioeconomic deprivation
This contributes to lower accessibility to a kidney specialist among different races and ethnic
groups (1)
From 2005-7 to the 2014-25, predialysis nephrology care increased from 30.1% to 39.5% for white
adults, 24.5% to 32.5% for Black adults, 21.2% to 28.3% for Hispanic adults, and 26.1% to 37.1%
After having received at least 12 months of predialysis nephrology care, the adjusted odds ratios
in
2005-2007: 0.82 for Black adults, 0.67 for Hispanic adults, and 0.84 for Asian adults in
comparison to white people
2014-2015: 0.76 among Black adults, 0.61 among Hispanic adults, 0.90 among Asian adults
(3)
THE RESULTS
Incident rates of ESRD are much higher among black and Hispanic patients than white
patients. (12)
Black and Hispanic patients experienced faster progression to CKD stage 5 compared with

white patients. Black patients with CKD stage 4 experienced slightly lower mortality than
white patients, whereas black patients with CKD stage 3 had a small increased risk of
death(3)
American Indians and Alaska Natives are twice as likely to have diabetes as White
Americans.
The rates of kidney failure caused by diabetes have doubled in Asian Americans ages
30-39 between 2000-2010.(3)
African Americans constitute about 12% of the US population but account for:
31% of end-stage renal disease
34% of the kidney transplant waiting list
28% of kidney transplants in 2015 (12% of living donor transplants, 35% of deceased
donor transplants).(14)
In addition, African Americans with chronic kidney disease tend to be:
Younger and have more advanced kidney disease than white (16)
Much more likely than whites to have diabetes, and somewhat more likely to have
hypertension
More likely than whites to die of cardiovascular disease (37.4% vs 34.2%)

Evaluation of Results With and Without Racial Coefficients
Wednesday, February 08, 2023 10:08 PM
Abstract
In this section we will summarize and compare statistical data taken from different studies exploring
methods for estimating the Glomerular Filtration Rate (GFR). The data that will be used are all taken
from verified sources that are cited in the last page of this section. During the first section of this page,
we will see that the studies would suggest that including racial coefficients in eGFR equations would
make results more accurate than otherwise. However it is important throughout this section to not
forget the flip side of the coin.
Studies Siding with Racial Coefficients to Be Used in eGFR Equations

In a study conducted by Ahmed, S., Nutt, C.T., Eneanya, N.D., in the Journal of General Internal
Medicine, there were a total of 56,845 from which 3.9% (2,225) were African-American. Their results
were as following:
If the racial coefficient would be removed from the eGFR equation, a percentage of 33.4% would be
classified as being in a more severe CKD stage. Additionally, 24.3% would move from stage 3B to stage
4, 3.1% would be placed in the eGFR 20 ml/min/1.73 m2 group rather than their previous eGFR >
ml/min/1.73 m2 group. This reclassification would make them meet the criteria for being prioritized for
a kidney transplant.
population-representative cross-sectional data from the United States National Health and Nutrition
Examination Survey. They found that 10.4% (3.3 million) more African-Americans would classify as Stage
3 CKD patients, and 0.1% (31,000) would be eligible for a kidney transplant waitlist, with the non-race-
corrected MDRD (Modification of Diet in Renal Disease) equation.
On a study posted on the Clinical Journal of the American Society of Nephrology on behalf of the
CREDENCE study investigators, there were 4401 participants of which:
67% were White
5% were African-American
20% were Asian
And 8% were other race
Their results suggested different conclusions than the previous ones. Without the racial coefficients, the
equation excluded 10% of African-American participants that would normally be categorized in the
eGFR<30 ml/min per 1.73 m2 group. Whereas with the 2021 CKD-EPI equation it would have excluded
6% less of these patients placed in the previously stated category and 0.4% from the eGFR 90 ml/min
per 1.73 m2. However, that same equation would exclude 0.7% of non-AA patients from the low eGFR
category and 7% from the high eGFR category. Although these results are self-contradictory, the authors
of the CJASN article state " eGFR recalculation without the race-specific coefficient had small but
potentially important effects on event rates and the relative proportion of Black participants without
substantially changing efficacy estimates".
The following charts visualize the statistical data acquired by the studies mentioned above

Studies Siding with Racial Coefficients to Not Be Used in eGFR
Equations
Although race-correction in eGFR equations might seem compelling due to the findings mentioned
above, it is important to note that not a sufficient amount of convincing results has been acquired
and people in the nephrological societies still argue for which equation is the most accurate.
Therefore, we are obligated to present both sides of the coin.
A study of patients in the US, showed that by removing the race-coefficient from the CKD-EPI
equation showed that approximately 2.5% of the African-American population in the United
States would be undiagnosed CKD patients with eGFR < 60 ml/min/1.73m2, 6.8% of whom would
have an eGFR <30 ml/min/1.73m2, and 3.7% would have an eGFR < 20 ml/min/1.73m2, assessing
them as patients waiting for a kidney transplant.

Furthermore, an article published in 2021 on the New England Journal of Medicine, included 8254
participants from different development data sets. The first data set included 4050 patients from
12 different studies, from which 14.3% were African-American, and the second one included 5323
participants from 13 different studies, in which 39.7% of them were African-American.
The first data set using race-corrected eGFR equations, overestimated the GFR by 3.7
ml/min/1.73m2 in African-American patients, and by 0.5 ml/min/1.73m2 in non-AA patients. The
second data set omitting race as a factor in the eGFR equation, underestimated measured GFR by
3.6 ml/min/1.73m2 in the AA population, and by 3.9 ml/min/1.73m2 in the non-AA population.
These results led to smaller differences between AA and non-AA participants being acquired by
the non-race-corrected equations.
The following charts visualize the statistical data acquired by the studies mentioned above

Works Cited
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Nephropharmacology, U.S. National Library of Medicine, 12 Dec. 2015,
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Estimated Glomerular Filtration Rate Calculation on African-
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20health%20inequities--%20race%20defiention.pdf.
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of Kidney Function: Estimations from U.S. Nhanes, 2015- EClinicalMedicine, U.S.
National Library of Medicine, 19 Nov. 2021,
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Transplantation Direct, U.S. National Library of Medicine,

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LWW,
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onsultation_and.15.aspx.
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https://www.kidney.org/atoz/content/minorities-KD.
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School of Public Health, 3 Sept. 2020, https://publichealth.jhu.edu/2020/the-racial-
inequities-of-kidney-disease.
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Nov. 2017, https://www.ccjm.org/content/84/11/855.
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LWW, Feb. 2021,
https://journals.lww.com/cjasn/pages/articleviewer.aspx?year=2021&issue=02000
&article=00020&type=Fulltext.
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International, https://www.medicalnewstoday.com/articles/egfr-african-american.
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https://doi.org/10.1056/nejmoa2103753.
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19. - and Cystatin C Based Equations to Estimate GFR
New England Journal of Medicine, vol. 385, no. 19, Massachusetts Medical
Society, Nov. 2021, pp. 1737 49. https://doi.org/10.1056/nejmoa2102953.

General Information on CAKUT
Background
CAKUT (Congenital Anomalies of the Kidney and Urinary Tract) is a broad group of abnormalities
affecting the kidneys or other structures of the urinary tract. Congenital meaning that the condition
exists at birth, CAKUT develops in children whilst they are still in the womb. It plays a role in 30-50% of
cases of chronic kidney disease requiring kidney replacement therapy in children and is oftentimes
diagnosed late/misdiagnosed.
CAKUT can manifest in many forms, which can range in severity from asymptomatic, to end-stage renal
disease.
CAKUT Page 27
Types of CAKUT
As the embryo develops, its kidneys take form, rotate, and move to their final adult positions. Thus,
different manifestations of CAKUT can depend on when and where an error in development occurs.
Categorization of CAKUT tends to be dependent on the specific type of reno-anomaly, as follows:

https://pubs.rsna.org/cms/10.1148/rg.2021200078/asset/images/large/rg.2021200078.fig4.jpeg
Anomalies of renal form Anomalies of renal fusion
Anomalies of renal position
Anomalies of renal number
Table providing an overview of variations of CAKUT:

https://pubs.rsna.org/doi/full/10.1148/rg.2021200078
CAKUT Page 28
CAKUT Page 29
Renal Form
Anomalies of renal form are structural anomalies of the kidney itself (eg, persistent fetal lobulation,
hypertrophied column of Bertin, and dromedary hump).
Persistent fetal lobulation is caused when there is incomplete fusion of the renal lobes during fetal
development. Though this is a relatively normal variation in kidney form, they have been mistakenly
confused for renal tumors in the past during scans.
https://radiopaedia.org/articles/persistent-fetal-lobulation-of-the-kidneys?lang=us#:~:text=Persistent%
20fetal%20lobulation%20is%20a,as%20they%20develop%20and%20grow.
https://casereports.bmj.com/content/2017/bcr-2017-219856
CAKUT Page 30
Renal Fusion
Horseshoe kidney
Horseshoe kidney refers to a condition in which the kidneys are fused at the lower poles
with an isthmus (a thin strip of tissue).
This isthmus is often either renal parenchymal (a type of organ connective tissue) or
fibrous.
The embryogenesis of horseshoe kidney with parenchymal isthmus is believed to be
abnormal migration of nephrogenic cells (progenitor cells during development).
The majority of horseshoe kidney patients are asymptomatic, but there is a higher risk of
Uretopelvic junction obstruction (UPJO), lithiasis, renal infection, renal lesions after
abdominal trauma
Increased malignancies/tumors (but still rare)
Pancake kidney
Pancake kidney is characterized by the complete median fusion of the two kidneys
Patients presenting pancake kidney are most often asymptomatic, but are more prone to
recurring UTIs and kidney stone formation
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4081266/#:~:text=Pancake%20kidney%20is%
20described%20as,ureters%20entering%20the%20bladder%20normally.
CAKUT Page 31
Renal Position
Ectopic Kidney
An ectopic kidney refers to a kidney located in a place where it normally shouldn't be.
Ectopic kidneys, which are often pelvic in location, result from errors of ascent during fetal development.
Rare case reports exist of thoracic kidneys. Ectopic kidneys can be unilateral or bilateral (affecting either one
or two kidneys, respectively).
Bilateral ectopic pelvic kidneys often fuse into a midline mass of renal tissue, with two distinct renal pelvises
and a variable number of ureters which is referred to as a fusion malformation called pancake kidney
(discussed earlier).
CAKUT Page 32
Renal Number
Renal agenesis
Renal agenesis refers to the complete loss of one or both kidneys without identifiable rudimentary
tissue.
Supernumerary kidney
A very rare condition, supernumerary kidney refers to the presence of an extra kidney. This
additional kidney may or may not be fused to the other kidneys, and there are very few cases of
this condition found in literature.
This condition is normally asymptomatic. However, symptoms may develop if the supernumerary
kidney also co-exhibits other kidney malformations (like pancake kidney, for example)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352298/#:~:text=The%20supernumerary%20kidney%
20is%20kidney,without%20division%20of%20ureteric%20bud.
CAKUT Page 33
Urinary collection system
Double Ureter
- This condition describes the duplication of the ureter tract. This duplication may be complete or
incomplete.
A complete duplication would imply that two ureters separately enter the bladder, while an
incomplete duplication would present as two ureters fusing before entering the bladder.
- In adults, most cases are asymptomatic.
- However, notably, children who present with double ureter have a 20x higher risk of renal
infection.
The image of a duplex kidney on the right shows an example of complete ureter duplication.
https://www.chop.edu/conditions-diseases/duplex-kidney
CAKUT Page 34
Causes
Genetic Inheritance
When inherited, CAKUT often follows an autosomal dominant pattern of inheritance, meaning
that only one faulty copy of a gene is necessary to be present for the condition to develop. This
monogenic inheritance has been found to account for up to 20% of cases in humans, and
variations in over 50 genes have been isolated as associated with the development of CAKUT.
Some notable examples are listed below.
https://molcellped.springeropen.com/articles/10.1186/s40348-021-00112-0
https://medlineplus.gov/genetics/condition/congenital-anomalies-of-kidney-and-urinary-
tract/#inheritance
HNF1B
The HNF1B gene provides instructions for making a protein that regulates the activity of
other genes involved in kidney and urinary tract development.
Mutations in HNF1B have been associated with renal hypoplasia (a condition where kidneys
do not grow to their normal size).
Notably, mutations in the HNF1B gene can increase the chance of both kidney defects and
diabetes, two comorbid conditions that affect renal health, as diabetic injuries can cause
nephron loss within the kidneys.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269211/#B3
PAX2
PAX2 is a gene that provides instructions for making a protein involved in the development
of the kidneys, eyes, and other tissues.
Mutations in the PAX2 gene have been associated with renal agenesis (condition in which
one or both kidneys fail to develop).
WT1
The WT1 gene provides instructions for making a protein that is involved in the
development of several tissues.
In relation to CAKUT specifically, mutations in WT1 have been associated with a higher
incidence of developing Wilm's tumor, a type of kidney cancer.
Environmental and Epigenetic Factors

https://www.researchgate.net/publication/281081472
_Genetic_environmental_and_epigenetic_factors_involved_in_CAKUT
- Factors that change the in-utero environment during development, such as maternal smoking,
depression, and BMI, have been shown to affect epigenetic methylation of certain genetic
sequences in the fetus.
Epigenetics refers to inherited changes that do not modify the DNA sequence itself. Rather,
the methylation or unmethylation of certain areas of the genetic sequence will allow certain
regions to become transcription un-accessible or accessible (respectively), meaning that
what genes are expressed in the fetus may be affected.
Factors during fetus development, such as maternal infections (some including rubella,
potentially increase the risk of CAKUT.

- It was also found that early exposure to maternal diabetes mellitus increases the risks of CAKUT.
- ingestion of antiallergic drugs in the first trimester of pregnancy????
- PAX2 functions in an epigenetic network that can be used to provide information about
CAKUT susceptibility and can potentially activate certain pathways in response to renal
CAKUT Page 35
injury. PAX2 is known to recruit PTIP, a protein that acts as a meythltransferase cofactor.
A study recorded that the lack of PTIP in the podocytes (cells of the kidney glomerus) of
mice resulted in glomerular sclerosis. Scientists propose that because PAX2 is a
developmental protein, it can contribute to the regulation of histone methylation which
would then form kidney epithelial cells that could act as a response to renal
complications.
CAKUT Page 36
Frequency and Diagnosis
CAKUT is responsible for 20% to 30% percent of all anomalies identified in the prenatal period and is
estimated to occur in 1 in 500 newborns.
Diagnosis is often determined by antenatal ultrasounds that examine the kidneys, outflow tracks, and
amniotic fluid. Amniotic fluid is the most important component to consider due to the fact that after the
18th week of pregnancy, it is primarily composed of urine that is produced by the kidneys.
Inconsistencies in the urine levels can indicate abnormalities in the kidneys. Antenatal ultrasounds
correctly diagnose CAKUT in 60%-85% of infants.
Ultrasound of fetus in amniotic fluid [1]
CAKUT can't always be diagnosed by antenatal sonography and in fact, it may only be determined
postnatally. Infants that begin to present symptoms (particularly those that experience UTI's frequently)
will undergo blood tests, urinalysis, voiding cystourethrography (an x-ray of the bladder and urethra
where a high-contrast fluid is injected via catheter into the bladder), and CT/MRI scans to get proper
diagnosis.
In measuring the magnitude of defects, a Serum Creatinine test can be used to estimate nephron
number within the patient's kidneys. Creatinine is a waste product in blood that comes from muscles.
Healthy kidneys filter creatinine out through urine, so a high level of creatinine indicates that the
kidneys are not working properly. Normal creatinine levels vary based on sex and age but, the general
normal level is 0.7-1.3 mg/dL for males and 0.6-1.1 mg/dL for females.
[1] Media, H. (2022, September 19). Amniotic fluid is sterile in uncomplicated term pregnancies. Infectious
Disease Advisor. Retrieved February 2, 2023, from
CAKUT Page 37
https://www.infectiousdiseaseadvisor.com/home/topics/prevention/amniotic-fluid-is-sterile-in-
uncomplicated-term-pregnancies/
CAKUT Page 38
Imaging
"Coronal T2-weighted MR image in a 40-year-old man shows a dromedary hump (arrowhead) from the
splenic impression (curved arrow)."
CAKUT Page 39
Ultrasonography of developmental kidney anomalies
(A) A large left dilated renal pelvis (stars) and thin renal cortical tissue consistent with
uretopelvic junction obstruction. (B) A multicystic dysplastic left kidney with multiple
parenchymal non-communicating kidney cysts of varying size (*) and hyperechoic,
dysplastic kidney tissue. (C) Autosomal dominant polycystic kidney disease with an
enlarged kidney showing multiple large cortical cysts (*). (A-C) The white dashed line
outlines the kidney parenchyma.
CAKUT Page 40
Underdiagnosis of CAKUT
Friday, February 3, 2023 11:33 AM
Studies show that CAKUT is particularly underdiagnosed in many developing countries. One study
conducted at the Dakar University Hospital in Senegal concluded that at this institution, diagnosis of
CAKUT before birth is poor, and the average age at which CAKUT is diagnosed is late. In fact, this study
found that the main impetus for diagnosis was the presentation of symptoms, most often a urinary tract
infection.
https://www.scirp.org/journal/paperinformation.aspx?paperid=118469
Thus, poor prenatal care may delay diagnosis till symptoms begin to present themselves in adolescence
Another issue with CAKUT is that underdiagnosis may be possible, as some people born with a low
nephron count will not exhibit symptoms till later in adolescence, or even adulthood.
CAKUT Page 41
Impact
-Chronic Kidney Disease

- This is a chronic condition of damaged kidneys
-Reduced Kidney Function
- A reduction in the kidney's function of filtering can cause the build-up of toxins in the blood
-Urinary Tract Infections
-Kidney Damage
-Need for dialysis/transplant
-Developmental Delay
CAKUT Page 42
Treatment
Patients with mild CAKUT cases get UTIs (or urinary tract infections) which result in kidney
problems like renal scarring and even cause kidney failure or ESRD. Many other issues also
develop from CAKUT including misshapen kidneys, hydronephrosis, and VUR(vesicoureteral
reflux) which causes UTIs and furthermore causes the conditions listed above.
Children with mild cases of CAKUT can learn different habits, called "voiding". Voiding is
described as "using different positions when going to the bathroom, taking a daily medication or
catheterizing the urinary tract to help with voiding of urine."
Even in mild cases, treatment options can also include operating on some of the urinary tract to
fix blockages. Such surgeries include:
Endoscopic surgery which is minimally invasive and involves the use of a stent to keep the
ureter open.
Open surgery which is more invasive and has a higher risk of infection.
Laparoscopic surgery which uses multiple incisions.
In more severe cases, ESRD stands for end stage renal disease and this means that a person's
kidneys no longer function. People with ESRD need either dialysis or a kidney transplant.
Kidneys that are misshapen in some way can be fixed through surgery such as:
Missing kidneys
Ectopic kidneys
Horseshoe kidneys
Cystic kidneys
Rotated kidneys
Duplex collecting kidneys, which causes the backflow of urine into the higher ureter
CAKUT Page 43
Often CAKUT results in VUR or vesicoureteral reflux and this can cause UTIs and renal
scarring. Treatment would be symptomatic, focusing on solving the problems CAKUT causes.
Treatment for VUR is surgically removing the blockage or fixing a ureter or bladder.
Treatment of Pediatric Vesicoureteral Reflux (VUR)
Treatment for UTIs include medication: Trimethoprim and sulfamethoxazole, Fosfomycin,

Nitrofurantoin, Cephalexin, Ceftriaxone, and Fluoroqyinokones.
Renal scarring treatment is more complicated because due to fluids no longer filtering
properly and building up, medicine is used to mediate swelling. However people with
CAKUT Page 44
severe renal scarring need either dialysis or a kidney transplant.
Citations:
CAKUT | Children's Hospital Colorado.
Congenital Abnormalities of Kidneys and Urinary Tract in Children at the Dakar University Hospital
Urinary tract infection (UTI) - Diagnosis and treatment - Mayo Clinic
Glomerulosclerosis | Johns Hopkins Medicine.
Congenital Anomalies of the Kidney and Urinary Tract: A Genetic Disorder?
Congenital Anomalies of the Kidney and the Urinary Tract (CAKUT) - PMC
Antiseptic drug as good as antibiotics for preventing recurrent UTIs.
Ureteral obstruction - Mayo Clinic.
CAKUT Page 45
Logistics
Donor matching
One critical factor affecting access to kidney transplants is the incompatibility of
donors with recipients. Often, a recipient will have a donor who is willing to
donate a kidney to them, but the two will be incompatible, so the procedure
cannot occur. Kidney Paired Donation (KPD) offers a solution to this problem by
pairing different donor-recipient pairs who are incompatible with each other but
compatible with their counterpart from the other pair. For example, if A is
willing to donate to B and C is willing to donate to D, but A is incompatible with
B and C is incompatible with D, it may be possible for A to donate to D and C to
B, thus fulfilling two recipient needs which would not have otherwise been
fulfilled. The National Kidney Registry (NKR) is a database of kidney donors in
the US which has facilitated hundreds of transplants annually for the past
decade. In South Korea, the concept of the KPD has been expanded to a kidney
chain, where incompatible pairs donate to other pairs with which they are
compatible in order to secure transplants for multiple patients at a time.
Kidney transport Eligibility

One major problem impacting access to kidney transplants is the logistics of
transporting live kidneys. Kidneys can only survive a maximum of 48 hours Potential Candidates for Kidney Transplantations:
outside of the body, and many must be transported long distances between Patients with ESRD (End-stage Renal Disease)
extraction and transplantation, especially when using national databases such as Patients with stage IV or V advanced chronic kidney disease with
the NKR. Because of this, kidneys must immediately be transported once a Glomerular Filtration Rate (GFR) less than 20ml/min.
extracted and must be quickly taken to the recipient for transplantation. Patients with stage IV chronic kidney disease that with a GFR less
than 30ml/min.
One significant advancement in kidney transport occurred in 2008, when a Patients with chronic kidney disease and type 1 Diabetes that is
kidney was shipped unaccompanied on a commercial airplane across the United not being treated can be considered for both a kidney and
States. This long-distance transport of kidneys allows for more efficient pancreas transplant.
implementation of KPD.
Another major innovation in kidney transport is the use of drones to transport Factors that could make you ineligible for a kidney transplant may
kidneys between hospitals. This solution could avoid the slowness of ground include:
transportation while also avoiding the excessive expense and risk of traditional
air transportation. Potential problems with this method of transportation Advanced age
include the temperature, forces, vibration, and pressure experienced by the Severe heart disease
kidney in flight, all of which could be detrimental to the survival of the kidney Cancer that is active or has recently been treated
and the quality of the transplant. Additionally, legal regulations on drones often Dementia or mental illness that is not well-managed
limit their potential range. As of 2022, a live kidney had been transported by Alcohol or drug abuse
drone four times for use in transplants. Any other factor that could compromise the safety of the
procedure and the ability to comply with post-transplant
medication regimen to prevent organ rejection.
Citations
Innovations in Kidney Paired Donation

Transplantation, Current Opinion, https://www.kidneyregistry.org/wp-
content/uploads/2021/03/Innovations-in-KPD-transplantation.pdf.
Matching Donors and Recipients, Apr. 2021,

https://www.organdonor.gov/learn/process/matching#:~:text=Many%
20kidneys%20can%20survive%20outside,patients%20from%20a%20wider%
20area.
Cleveland Clinic,
https://my.clevelandclinic.org/departments/transplant/programs/kidney/candid
ate.
Mayo Clinic, Mayo Foundation for Medical Education and

Research, 3 May 2022, https://www.mayoclinic.org/tests-procedures/kidney-
transplant/about/pac-20384777.
Kamberi, S. S., Gavzy, S. J., Shockcor, N., & Scalea, J. R. (2022). Development and
Implementation of Unmanned Aerial Vehicles for Donor Organ Transportation.
Treatments for Chronic Kidney Disease Page 46

Innovations in Nephrology. https://doi.org/10.1007/978-3-031-11570-7

Shortage
Kidney Donor Types

Kidney transplants are generally split into two categories: deceased-donor kidney transplants and Living-Donor Kidney Transplants are a procedure in which a healthy
living-donor kidney transplants. In a deceased-donor kidney transplant, a kidney is harvested individual donates a kidney, which is then surgically transplanted into
from a deceased donor and transplanted into a patient whose kidneys are not functioning a person with kidney failure. Compared to deceased kidney transplants,
properly. In a living-donor kidney transplant, the kidney is taken from a living donor instead. liver donor transplants offer several benefits, including:
A higher success rate

There are several different categories for deceased donor organs: Immediate function of the transplanted kidney after surgery,
Standard Criteria Donors (SCD): Kidneys are harvested from donors under the age of 50 and do compared to a few days or weeks for a deceased donor kidney
not meet two of the following criteria: a history of high blood pressure, the donor passed away The ability to schedule the procedure for both the recipient and
from a stroke, or had a creatinine level higher than 1.5 mg/dl. donor, whereas with a deceased donor transplant, surgery must
Expanded Criteria Donors (ECD): Kidneys are harvested from donors over the age of 50 and have be performed quickly after the availability of a kidney
at least two of the following criteria: a history of high blood pressure, the donor passed away from Reduced risk of rejection, especially if the kidney is from a blood
a stroke, or had a creatinine level higher than 1.5 mg/dl. relative
Donation after Cardiac Death (DCD): Occurs when the donor is someone who is near death but Shorter waiting time for the transplant, as the average wait time
has suffered extreme brain injury and dies from cardiac arrest, but is not included in the formal for a deceased donor kidney can be up to five years.
brain death criteria.
Double Kidney Transplants (Duals): During the year, donors with expanded criteria may be
available. Research has shown that transplanting both of these kidneys into one recipient is better
than using just one.
High-Risk Social Behavior Donors: These donors have engaged in high-risk behavior for sexually
transmitted diseases, drug use, or have a history of incarceration. All donors undergo testing for
transmissible diseases at the time of organ recovery, and you will be informed of their high-risk
behavior.
Kidney fabrication
A potential solution to the current shortage of kidneys for transplantation is kidney fabrication. Another potential source for kidneys is through growing them directly
There are a few potential methods for this, none of which have been fully successful yet and all of from stem cells. This technique is promising, but relies heavily on
which have their own advantages and disadvantages. understanding the natural process of kidney growth, which is not fully
One potential route to take would be 3D fabrication of kidneys with techniques similar to 3D understood.
printing. The advantage of this would be similar to the advantages of 3D printing in general speed A final potential technique is chimerism, which combines
and flexibility. The primary reason that this has not yet been achieved is because the kidney is an xenotransplantation and growing kidneys from stem cells. The idea
behind this technique is to genetically engineer a kidney growing in
too complex to print with current technology. Individual organelles can sometimes be printed, another animal to be more compatible with humans. This fixes the
but combining the organelles into a fully functional order has not yet been accomplished. The problem of rejection through genetic engineering and is easier than
challenge is only made harder by the fact that the exact function of the kidney is still not fully growing a kidney from stem cells because it allows them to grow
understood. within the scaffolding of an animal.
Another potential kidney fabrication technique is xenotransplantation. This is a technique in
which a kidney is grown in an animal (usually a pig) and then transplanted into a human. This
technique came about because of the difficulty of creating kidneys from scratch and their ability
to naturally grow in animals. Currently, there have been promising attempts at the
transplantation of kidneys from pigs to baboons, with the organs lasting over twelve months after
transplantation, but there have not yet been any successful human trials. The main setback facing
xenotransplantation is immune rejection. The immunoreaction when transplanting an organ from
an animal to a human is even stronger than the reaction when transplanting between humans,
which itself is a problem for regular transplants.
Citations
Cleveland Clinic,
https://my.clevelandclinic.org/departments/transplant/programs/kidney/types.
Nonaka, T., Nakayama, K., Hara, H., Murata, D., & Nagaishi, Y. (2022). 3D Printing in Nephrology.
Innovations in Nephrology. https://doi.org/10.1007/978-3-031-11570-7
Yamanaka, S., & Yokoo, T. (2022). Generation of Whole Kidney and Other Possible Strategies to
Renal Replacement Therapy in the Future. Innovations in Nephrology.
https://doi.org/10.1007/978-3-031-11570-7

Surgery
Robotic surgery
Using Da Vinci SP: Single port robotic surgery
Single port surgery - -operative pain and no opioids needed
Compared with the standard open approach, multiport robotic-assisted kidney

transplantation (RAKT) has emerged as a less morbid alternative.
Single-port robotic surgery was performed through a 5-cm midline periumbilical abdominal
incision with transperitoneal or extraperitoneal approaches.
Standard Surgery
Laparoscopic nephrectomy:
A few, very small cuts are made in your belly (abdomen). These are used to put surgical
instruments into the abdomen. A very small camera is also used to help the surgical team
see inside. Then a 7 to 10 cm (3 to 4 inch) incision is made so they can take out the kidney.
Occasionally during the surgery, the procedure may need to be changed from laparoscopic
to open nephrectomy.
Open Nephrectomy:
Cleveland Clinic's First in the World to Perform
Robotic Single-Port Kidney Transplant
Citations
Using Single- News 5 Cleveland WEWS, News 5 Cleveland WEWS, 5 Nov.

2019, https://www.news5cleveland.com/lifestyle/health-and-fitness/cleveland-clinic-
doctors-perform-worlds-first-kidney-transplant-using-single-incision-robot.
-Port Kidney
Cleveland Clinic Newsroom, Cleveland Clinic Newsroom, 5 Nov. 2019,
https://newsroom.clevelandclinic.org/2019/11/05/cleveland-clinic-first-in-the-world-to-
perform-robotic-single-port-kidney-transplant/.
Kaouk J;Eltemamy M;Aminsharifi A;Schwen Z;Wilson C;Abou Zeinab M;Garisto J;Lenfant

-Port Robotic-Assisted Kidney Transplantation and
European Urology, U.S. National Library of Medicine,
https://pubmed.ncbi.nlm.nih.gov/33810922/.
MyHealth.Alberta.ca Government of Alberta Personal Health

Portal, https://myhealth.alberta.ca/KidneyTransplant/living-kidney-donation/types-of-
surgery.

Normal Surgery
Wednesday, February 8, 2023 8:34 PM
Kidney transplant surgery
The kidney transplant procedure involves 3 main stages:
First, an incision (cut) is made in your lower abdomen (tummy), through which the donated kidney
is put into place. Your own kidneys will usually be left where they are, unless they're causing
problems such as pain or infection.
Second, nearby blood vessels are attached to the blood vessels of the donated kidney. This is to
provide the donated kidney with the blood supply it needs to function properly.
Finally, the ureter (the tube that carries urine from the kidney to the bladder) of the donated
kidney is connected to your bladder.
A small plastic tube called a stent may be inserted into the ureter to help ensure a good flow of urine
initially. This will usually be removed about 6 to 12 weeks later during a minor procedure called
a cystoscopy.
When the kidney is properly in place, the incision in your abdomen will be closed with surgical staples,
stitches or surgical glue.
Although the procedure may sound relatively straightforward, it's very demanding and complex surgery
that usually takes around 3 hours to complete.
Citations:
https://my.clevelandclinic.org/health/treatments/22537-kidney-
transplant
https://www.nhs.uk/conditions/kidney-transplant/what-happens/#:
~:text=First%2C%20an%20incision%20(cut),vessels%20of%20the%
20donated%20kidney.

Robotic Surgery
Da Vinci SP
Single port robotic surgery
Interesting Fact!
The nonfunctioning kidneys are not removed unless causing
Discomfort, and the new kidney is installed in the lower abdomen.
The worlds first single port robotic surgery was performed in

Cleveland in 2019. The benefit of single robotic surgery is that
only one abdominal incision is made. Below is a video detailing
the surgery. T
Cleveland Clinic's First in the World to Perform Robotic

Single-Port Kidney Transplant
Benefit of robotic surgery is that it offers an alternative for

patients dealing with obesity or challenging anatomy. It is a
minimally invasive surgery.
Citations

Laparoscopic Donor Nephrectomy
Laparoscopic surgery is a technique which uses narrow tubes (trochars) that are inserted into
the abdomen through a small incision. Small instruments can be used to perform an
operation. Carbon Dioxide gas is used to push the stomach wall up and a camera is inserted
through the trochars so the surgeon can view the surgery.
How does a laparoscopic (scarless) donor nephrectomy work?
Laparoscopic donor nephrectomy through the belly button
Another procedure that involves more incisions.
A few, very small cuts are made in your belly (abdomen). These are used to put
surgical instruments into the abdomen. A very small camera is also used to help the
surgical team see inside. Then a 7 to 10 cm (3 to 4 inch) incision is made so they can
take out the kidney. Occasionally during the surgery, the procedure may need to be
changed from laparoscopic to open nephrectomy.
Citations
https://medlineplus.gov/ency/presentations/100166_1.htm#:
~:text=Laparoscopic%20surgery%20is%20a%20surgical,%2C%
20cut%2C%20and%20sew%20tissue.

Rejection
Compatibility testing Immunosuppressive drugs

There are three tests that are done to evaluate compatibility: blood type, crossmatch, Immunosuppressive drugs suppress the immune
and HLA (human leukocyte antigen) testing. system and prevents the immune system from
Blood Typing: This tests finds out what blood type the patient has. The rules for rejecting newly transplanted kidneys.
blood typing is the same as those for blood transfusion. Types of Immunosuppressants:
Donor Available Recipients Biologics
Calcineurin Inhibitors
Type O Type O, A, B, AB
Corticosteroids
Type A Type A, AB Inosine Monophosphate Dehydrogenase
Type B Type B, AB Janus Kinase Inhibitors
Type AB Type AB Mechanistic Target of Rapamycin Inhibitors
Monoclonal Antibodies
Crossmatching: This test is essentially a test blood transfusion between the
Risks and Complications of Immunosuppressants:
recipient and the donor to measure compatibility by seeing how the two bloods
Blood Infections
react. There are two types of crossmatching tests:
Fungal Infections
Major Crossmatching- A mandatory test where the donor's blood cells are
combined with blood serum from the recipient. This tests whether or not Skin Infections
the recipient has any antibodies that resists the donor's blood cells. Respiratory Infections
Minor Crossmatching: A non-mandatory test where the donor's blood
serum is combined with the blood cells of the recipient. This tests whether
or not the donor has antibodies that could work against the recipient's
antigens.
HLA Typing: Also known as "tissue typing", is a way to test how strong the
recipient's antibodies against donor's human leukocyte antigens. If the
recipient's antibodies are strong against the donor's antigens, the risk of rejection
is high.
Citations
Mayo Clinic, Mayo Foundation for Medical Education and Research, 3
May 2022, https://www.mayoclinic.org/tests-procedures/kidney-
transplant/about/pac-20384777#:~:text=Most%20kidney%20transplant%20recipients%
20can,checkups%20as%20you%20continue%20recovering.
UC Davis Health,
https://health.ucdavis.edu/transplant/livingkidneydonation/matching-and-
compatibility.html.
WebMD, WebMD,
https://www.webmd.com/a-to-z-guides/what-is-blood-crossmatching.
Cleveland Clinic,
https://my.clevelandclinic.org/health/drugs/10418-immunosuppressants.

After Transplant
Side effects of Immunosuppression Neurological consequences

Immunosuppressants protects the transplanted kidney from potential attacks by Children with kidney failure are likely to have abnormal
the body's immune system. neurodevelopment
Types of side effects The younger, the higher the risk
High blood pressure Compared to healthy children, pediatric kidney transplant
Increased risk of infections & diabetes & skin cancer recipients are in the impaired, borderline, or low-average
Weight gain intelligence range
Diarrhea Memory deficits, attention problems are common
Abdominal pain
Bone thinning, easy bruising or bleeding
Mood swings
Acne
Swollen gums
Hair gain or loss
It is important to find the right dosage (high enough to boost the immune system
but low enough to prevent side effects).
General Health
newly transplanted organs.
Glomerular Filtration Rate(GFR): the rate of kidney filtering various

substances inferred by blood or urine concentrations
Normally Functioning Kidney - GFR constant, Plasma creatinine is excreted
at a constant rate
Seeah Kim at 2023/02/08 8:39 PM
Recently Transplanted Kidney - GFR and plasma creatinine are inversely
related.
Biological Changes measured by monitoring plasma creatinine
Immune System
Immature immune systems in infants cause higher risks of infection
Weak towards BK and JC polyomavirus, CMV, and EBV Journal of the
20% of pediatric recipients fall into high-risk category for CMB Royal Statistical Society. Series D (The Statistician), vol. 32, no. 1/2, 1983, pp.
40% for EBV 46 54. JSTOR, https://doi.org/10.2307/2987591. Accessed 9 Feb. 2023.
Pediatric Transplant Recipients

Superior growth, improved neurocognitive development, academic
performance than children treated with dialysis
1st high-risk interval: early post-transplant period
2nd high-risk interval: adolescence and young adulthood
Infants receive adult donor kidney (required to be at least 6~10kg)
Transplanted kidney must accommodate large changes in body size
Potential Infections: Cytomegalovirus CMV, Epstein-Barr virus EBV
Comparison of international pediatric kidney transplant recipient
characteristics
Primary Diseases
Congenital anomalies of the kidneys
Lifelong bladder dysfunction -> requires continuous urology care
Risk of urinary tract infections, obstructive nephropathy ->
Oxybutynin prescribed
Intermittent assessment of bladder function necessary
-Term Care of the Pediatric Kidney Transplant
LWW,
https://journals.lww.com/cjasn/Fulltext/2022/02000/Long_Term_Care_of_the_
Pediatric_Kidney_Transplant.18.aspx.
Therapy & Long-Term Care
Usually have a dietician.
Exercise regularly.
After Surgery
Avoid behaviors that negatively affect health. Spend several days to week in a hospital
Transfer from pediatric to adult-oriented care Your new kidney will make urine like your own kidneys did when they were healthy.
Age: 18-21yrs (middle of the period of peak graft failure risk) Often this starts immediately. In other people, it may take several days, and you may
Risk of graft failure after transfer depends on age at transfer need temporary dialysis until your new kidneys begin to function properly.
Study of 440 American transplant recipients Normal pain associated with the surgery
57% higher risk transferred at <21 years than recipients transferred at
21yrs
Açe is not adequate in supporting immunosuppressive medications
Pediatric care - more nurturing and family focused
Adult care - focused on the autonomy of patient

Citations
Mayo Clinic, Mayo Foundation for Medical Education and
Research, 3 May 2022, https://www.mayoclinic.org/tests-procedures/kidney-
transplant/about/pac-20384777#:~:text=Most%20kidney%20transplant%20recipients%
20can,checkups%20as%20you%20continue%20recovering.
-Term Care of the Pediatric Kidney Transplant

LWW,
https://journals.lww.com/cjasn/Fulltext/2022/02000/Long_Term_Care_of_the_Pediatri
c_Kidney_Transplant.18.aspx.
Journal of the Royal

Statistical Society. Series D (The Statistician), vol. 32, no. 1/2, 1983, pp. 46 54. JSTOR,
https://doi.org/10.2307/2987591. Accessed 9 Feb. 2023.
- NHS Choices, NHS, 19 Aug. 2022,

https://www.nhs.uk/conditions/kidney-transplant/risks/.

Topic 3: Group 5
Global impact of chronic kidney disease (CKD)

CKD terminology and different forms
Diabetic kidney disease (DKD)
Hypertensive nephropathy
End-stage renal disease (ESRD)
Sean: Quality Control (QC) Officer: ensures that overall segment fulfills the tasks outlined by the prompt
and that different elements of the segment work together seamlessly and as intended
Danielle: Fact Check Officer: ensures that every fact and claim introduced in the document is accurate,
including the details of the cited references
Brianna: Design Integration Officer: ensures that all the graphical and informational elements in the
segment are designed and implemented cohesively within the project (compared to all the other groups)
Video?: Chronic kidney disease - causes, symptoms, diagnosis, treatment, pathology
CKD Page 56
Global Impact of Chronic Kidney Disease
According to the World Health Organization, Chronic Kidney Disease is the 10th leading
cause of death worldwide. It is estimated 10% or 800 million individuals are impacted
globally, yet many speculate that percentage to be higher. While it is a widespread
issue, low to mid income countries face a greater prevalence of cases and less access
to medical care. In 2010, a study was constructed to summarize the results of 33
population-based studies of representative groups of individuals older than 20 years.
The study reported a CKD age-standardized prevalence of 9.6% in women and 8.6% in
men for high income countries, while in low-mid income countries there was a
prevalence of 12.5% in women and 10.6% in men. Poorer countries are
disproportionately affected as younger adults are more likely to develop CKD, due to
hypertension and glomerulonephritis, and proper medical care is financially
inaccessible. Overall, the global burden of kidney disease is increasing due to factors
including aging populations, increasing rates of hypertension, and rising rates of obesity
and diabetes, thus early detection and treatment is important to reduce its impact on
society as a whole.
CKD Page 57
Diabetic Kidney Disease (DKD)
Definition
Diabetic Kidney Disease (DKD) is a condition that results from Type 1 and Type 2 diabetes. If not
well managed, diabetes can lead to high sugar levels and high blood pressure. As a result, the
glomeruli in the kidney are narrowed and experience damage. Specifically, DKD promotes the
thickening of the glomerular basement membrane, capillary, and tubular basement membrane of
it lowers blood flow.
Causes of Diabetic Kidney Disease + How Diabetes promotes it

To start, what is diabetes and what are its different types? Type 1 Diabetes (DM1) is a genetic
condition in which the pancreas produces little to no insulin, which is a hormone that lowers blood
still able to produce insulin, however, their bodies are resistant to it.
Risk factors of DKD are hyperglycemia and hypertension, both of which are promoted by diabetes.
Hyperglycemia is a condition in which patients experience high blood sugar levels and
Hypertension is a condition in which patients have high blood pressure. Both high blood sugar
levels and high blood pressure narrows and clogs blood vessels in the kidney, ultimately reducing
Additionally, diabetes damages the nerves in your body, including the ones that signal to your
brain that your bladder is full. A full bladder can put pressure on your kidneys and damage them,
as well as cause Urinary tract infections that can spread to your kidneys.
Diagnosis
eGFR, estimated glomerular filtration rate, is a marker used to evaluate renal function. DKD is
diagnosed by a sustained reduction in eGFR less than 60 ml/min per 1.73m2. In addition, when the
kidney becomes damaged, a protein called albumin passes through the kidney and ends up in
the urine. Hence, testing the levels of albumin in urine is a good way to evaluate the condition of
the kidneys. Patients with consistently high urinary albuminuria-to-creatinine ratio of less than
30mg/g can be diagnosed with DKD.
For patients with Type 1 Diabetes, screenings start taking place 5 years after their diagnosis and
occur annually. For Type 2 Diabetes, patients start screening at the start of their diagnosis and
occur annually. Statistically speaking, approximately 30% of DM1 patients develop DKD while 40%
of DM2 patients develop DKD. About of all diabetics have DKD.
Treatment
The best approach to treating and preventing DKD is long-term intensive glycemic control early on
treatment plan. In a study, patients with DM1 were able to reduce the 9 year risks of developing
microalbuminuria and macroalbuminuria. In a median 22 year follow up for the study, the group
had approximately 50% lower risk of a low eGFR, and the average rate of eGFR loss was 0.46
ml/min less compared to those with standard therapy (a lower the eGFR signifies that the kidney is
not filtering as well). However, glycemic control fails to reduce risk of DKD progression after long
standing diabetes and complications caused by it, which is why it is emphasized to start treatment
at the start of diabetes diagnosis.
Citations
Diabetes and Kidney Disease (Stages 1-4)
Diabetic nephropathy (kidney disease) - Symptoms and causes - Mayo Clinic
CKD Page 58
Progression of diabetic nephropathy - ScienceDirect
Diabetic Kidney Disease Challenges, Progress, and Possibilities
CKD Page 59
Hypertensive Nephropathy
Definition
Hypertensive kidney disease is caused by uncontrolled hypertension(high blood
pressure; It is when blood pressure is above 140/90, and is considered severe if it is
above 180/120). It is the second leading cause of end-stage renal disease (ESRD) after
diabetes. Most hypertensive patients develop mild-to moderate hypertensive
nephrosclerosis. Hypertensive nephrosclerosis is progressive kidney damage that is
caused by hypertension, and is one of the common causes of ESRD. High blood
pressure injures tubular cells, which can lead to epithelial mesenchymal transition (EMT)
and tubulointerstitial fibrosis. EMT is when epithelial cells gain migratory and invasive
properties to become mesenchymal stem cells, and tubulointerstitial fibrosis is a
progressive detrimental connective tissue deposition on the kidney, which leads to
renal function deterioration.
Prevalence
Hypertension affects 30% of the general population, and it is approximately twice as
prevalent in patients with diabetes. Hypertension can be commonly found before
kidney disease, and the risk factors of glucose intolerance and hypertension can be
used to explain the association between the two. Most of the patients develop
hypertensive nephrosclerosis. It is the leading cause of ESRD in the United States, with an
incidence rate of 158 cases per million.
Treatment
Control over blood pressure requires multiple hypertensive agents, such as ACEI or ARB,
as it can reduce blood pressure by targeting the effects of Ang II. Angiotensin is a
chemical that narrows blood vessels, which causes increase in blood pressure, and
Angiotensin II blocks those receptors to prevent the chemicals from releasing. Other
agents such as clonidine, vasodilators (hydralazine and minoxidil), and alpha-blockers
may be needed with persistent hypertension. Hypertension in diabetic nephropathy
should be treated through therapies that block angiotensin production. Blood pressure
should be lowered to less than 130/80 mm Hg, and will require a combination of
nonpharmacologic intervention and antihypertensive drugs. Nonpharmacologic
intervention techniques include exercise, weight loss, reduced alcohol consumption,
and relaxation techniques.
Resources
https://academic.oup.com/ckj/article/13/4/504/5900707
https://www.sciencedirect.com/science/article/pii/S1548559510001552?via%3Dihub
https://www.sciencedirect.com/science/article/pii/S1548559510001783
CKD Page 60
End Stage Renal Disease
Definition
kidneys permanently cease normal function, leaving them dependent on dialysis or a

transplant in order to survive more than a matter of weeks. ESKD is an incredibly fatal
condition even with proper treatment, with the highest mortality occurring within 6
months of dialysis, and a 35% 5-year survival rate.
Diagnosis
CKD is typically diagnosed according to kidney damage markers that determine
proteinuria and glomerular filtration rate (GFR). According to the Kidney Disease
Improving Global Outcomes foundation guidelines, an individual is considered to have
CKD given that there is less than 60 mL/min GFR along with irregular kidney function for
at least a 3 month period. Comparatively, end-stage kidney disease is defined as the
presence of less than 15 mL/min GFR. However, diagnosis can also be determined
solely by the patient's symptoms and quality of life. End-stage renal disease can present
through a variety of symptoms including anemia, hypertension poorly responsive to
treatment, mineral and bone disorders, protein energy malnutrition, muscle weakness,
loss of lean body mass, metabolic issues including hyperkalemia, hyponatremia,
metabolic acidosis, hypo/hypercalcemia and hyperphosphatemia.
Prevalence
Considering the most common causes of ESKD include diabetes and high blood
pressure, older males are disproportionately impacted by this disease. As an individual
ages, the prevalence of CKD increases from 6% at age 18-44 to 31.8% at age 65 with a
large percentage of cases eventually progressing to the point of ESKD. In 2015, there
were 124,411 new ESKD diagnoses according to the United States Renal Data System,
thus implying an increasing burden of kidney failure. Accordingly, the prevalence has
been increasing at a constant rate of around 20,000 individuals each year.
CKD Page 61
Citations
https://www.ncbi.nlm.nih.gov/books/NBK499861/#:~:text=The%20mortality%20rates%
20for%20patients,followed%20by%20adverse%20cardiac%20events.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9073222/#:~:text=Chronic%20kidney%
20disease%20is%20a,experiencing%20diabetes%20mellitus%20and%20hypertension.
CKD Page 62
Preventative vs. Palliative Care
What is preventive care?

It is routine health care that helps detect or prevent illness and diseases.
These steps for care are taken BEFORE any major health problem or disease
occurs. Examples of such care include annual check-ups, immunizations,
shots, and screenings.
Source: [https://www.cigna.com/knowledge-center/preventive-care]
What is palliative care?

It is an approach that addresses the person and their needs, not just their
disease. It treats symptoms and side effects of diseases/treatment and
treats any related psychological emotional, social, practical, and spiritual
problems. It leads to an overall improved quality of life.
Source: [https://medlineplus.gov/ency/patientinstructions/000536.html]
Kidney Disease Palliative Care

Palliative care can highly benefit patients with chronic kidney disease
"experience poor quality of life and decreased survival expectancy."
"Palliative care requires close collaboration among multiple health care
providers, patients, and their families to share the diagnosis, prognosis,
Palliative care for kidney disease patients are often times for the
patients in the terminal phase with serious illness; it is often confused
with hospice care.
Source: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9267754/]
Preventative and Palliative Care Page 63

Common problems/issues and best
practices to address them
____________________________________________________________
PART 1: Common Problems
____________________________________________________________
1. Late diagnosis and treatment:

Many people with kidney disease are not diagnosed until the disease is advanced,
which limits treatment options. Kidney disease often gets worse over time and may
lead to kidney failure and other health problems, such as stroke or heart attack.
More than 1 in 7, that is 15% of US adults an estimated 37 million Americans, are

estimated to have CKD.
For Americans with diabetes or high blood pressure the two most common
causes of kidney disease the risk for CKD is even greater. Nearly 1 in 3 people with
diabetes and 1 in 5 people with high blood pressure have kidney disease. Other risk
factors for developing kidney disease include heart disease and a family history of
kidney failure.
These two conditions were the primary diagnosis in 76% of kidney failure
cases between 2015-2017.
The major takeaway is:

As many as 9 in 10 adults with CKD do not know they have CKD.
About 2 in 5 adults with severe CKD do not know they have CKD.
Graph:

*Percentage of CKD stages 1 4 among US adults aged 18 years or older using data from the
2015 2018 National Health and Nutrition Examination Survey and the CKD Epidemiology Collaboration
(CKD-EPI) equation. (Source: https://www.cdc.gov/kidneydisease/publications-resources/ckd-
national-facts.html)
2. Inadequate access to care:

Many people with kidney disease, particularly those in low and middle-income
countries, lack access to the health care services they need
An estimated 1 million people worldwide die from untreated kidney failure each
year. CKD is the ninth leading cause of death in the United States. (Source: The
George Washington University, 2022)
CKD affects more than 1 in 7 U.S. citizens. (Source: National Institute of Diabetes
and Digestive and Kidney Diseases, 2021)
Graph:

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9073222/
3. Poor adherence to treatment regimens:

People with kidney disease often struggle to adhere to complex and time-
consuming treatment regimens, which can compromise their health and lead to
treatment failure.
4. Symptom management:
People with advanced kidney disease often experience a range of symptoms,
including fatigue, muscle cramps, and sleep disturbances, which can significantly
impact their quality of life.
5. Depression and anxiety:

Kidney disease can be a source of emotional distress, and people with the
condition are at increased risk of depression and anxiety.
_____________________________________________________________
PART 2: Best practices:
____________________________________________________________
1. Early screening and diagnosis:

Regular screening and early diagnosis of kidney disease can help prevent its
progression and preserve kidney function.
Startup: Scanwell Health
2. Multidisciplinary care:
A team approach that involves a variety of health care professionals can help
people with kidney disease receive comprehensive and coordinated care.

3. Patient education:
Education and support can help people with kidney disease better understand their
condition, adhere to their treatment regimens, and manage their symptoms.
For instance:
National Kidney Disease Education Program
4. Symptom management:
Symptom management strategies, such as physical therapy and pain
management, can help improve quality of life for people with kidney disease.
5. Psychological support:
Providing emotional support and referral to mental health services can help people
with kidney disease cope with the psychological impact of their condition.

Differences in care between regions/countries/time
1. Asia:
In many Asian countries, traditional and alternative medicine are widely
used in conjunction with modern medicine for the treatment of kidney
diseases. Preventative care may focus on early detection and lifestyle
modifications to reduce the risk of kidney disease, such as reducing
salt and protein intake and increasing physical activity. Palliative care for
advanced kidney disease may involve the use of traditional herbal
remedies to manage symptoms.
2. Europe:
European countries have well-established healthcare systems and a
strong emphasis on evidence-based medicine. Preventative care may involve
regular screening and monitoring of kidney function, as well as
education on lifestyle modifications to reduce the risk of kidney disease.
Palliative care for advanced kidney disease often includes access to hospice
and palliative care facilities, as well as the use of dialysis and kidney
transplantation.

3. North America:
In the United States and Canada, the healthcare system is primarily private,
with a focus on specialty care and the use of advanced medical
technologies. Preventative care for kidney disease may involve regular
screening and monitoring, as well as access to lifestyle modification
programs. Palliative care for advanced kidney disease often involves the use
of dialysis and kidney transplantation, as well as access to hospice and
palliative care services.
A dialysis machine
4. Sub-Saharan Africa:
Palliative care for patients with kidney disease in Sub-Saharan Africa faces
several challenges, including limited resources, inadequate healthcare
infrastructure, and a shortage of trained healthcare providers.

The cost of care in developed countries for kidney disease can be high,
with many patients requiring extended stays in hospital or specialized
facilities. In Sub-Saharan Africa, the cost of care is often a barrier to
accessing palliative care, as many patients are unable to afford the
necessary medical treatment.
Also, access to dialysis, a common form of treatment for kidney failure, is

limited in many parts of Sub-Saharan Africa. In developed countries, dialysis
and transplantation are widely available and considered to be standard
treatments for kidney failure. However, for Sub-Saharan Africa, these
treatments are often not available or are not a viable option due to a lack of
resources and trained healthcare providers.
In addition, kidney transplantation is often not a viable option due to a
lack of available donors, limited surgical facilities, and a shortage of
immunosuppressive medications. There is a need for increased
investment in palliative care services and training for healthcare
providers in the region. This will help to ensure that patients with kidney
disease receive the care they need to manage their symptoms and
maintain a good quality of life, even in the face of a life-limiting illness.
Additional Readings:
1)Health-related quality of life, palliative care needs and 12-month survival
among patients with end stage renal disease in Uganda: protocol for a mixed
methods longitudinal study - BMC Nephrology
Those with chronic kidney disease have a high symptom burden and a poor-
quality life. the only option for care are renal replacement therapies. With a
rise of chronic kidney disease in sub-Saharan African, the only form of care
can be given are from renal replacement therapies such as hemodialysis.
associated with catastrophic expenditures and increased household poverty

2)Comparison of the health-related quality of life of end stage kidney
disease patients on hemodialysis and non-hemodialysis management in
Uganda - BMC Palliative Care
-related quality of life is recognized as a key outcome in chronic
disease management, including kidney disease. With no national healthcare
coverage for hemodialysis, Ugandan patients struggle to pay for their care,
driving families and communities into poverty. Studies in developed
countries show that patients on hemodialysis may prioritize quality of life
over survival time, but there is a dearth of information on this in developing

Low-Cost Approaches to Care
____________________________________________________________
Preventative Care
____________________________________________________________
One low-cost approach to preventive care is for high-risk individuals for

kidney disease to have screenings for early detection of the disease. Kidney
1. What are screenings?

Kidney screening tests work by measuring various biomarkers in the blood
or urine that can indicate the presence of kidney disease.
The most common screening test for kidney disease is a blood test that
measures the level of creatinine, a waste product produced by the
muscles that is filtered out of the blood by the kidneys.
High levels of creatinine in the blood can indicate that the kidneys are
not functioning properly. Other kidney screening tests may include a
urine test to measure the level of protein, tests for high blood pressure,
or imaging tests such as an ultrasound or MRI. These tests help doctors
diagnose and monitor kidney disease, and can help determine the best
course of treatment.
It is recommended for high-risk individuals are for targeted screenings
those with family history of CKD, individuals receiving potentially

nephrotoxic drugs, herbs or substances or taking indigenous medicine,
patients with past history of acute kidney injury, and individuals older
Lower middle-income countries (LMIC) are not well prepared or

equipped to deal with the consequences of chronic kidney disease,
CKD is not recommended and it was claimed that it might add
-risk individuals, but

also extend to those with suboptimal levels of risk, e.g.,
Another low-
risks for kidney disease, such as blood pressure control and effective
development of kidney disease.

As shown in the figure below, there are three levels of prevention care
steps that can be taken to ensure kidney disease does not escalate in
patients.
Graph:
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7076785/
____________________________________________________________
Palliative Care
____________________________________________________________
There are several low-cost approaches to providing palliative care for

patients with kidney disease:
Method 1: Using Community-Based Resources

This approach involves working with community health workers,
volunteers, and other community members to provide palliative care
services.
This can be a cost-effective way to provide care, as it leverages
existing resources within the community. Also, utilizing existing
resources such as local hospitals, clinics, and community centers

can lower costs by reducing the need for expensive inpatient
facilities.
Kidney disease presents challenges with patient self-management which
leads. This lack of self-management creates a risk of complications and
decreased quality of life for those with kidney disease.
The only way patients can have positive health outcomes is to be
able to "manage the day-to-day tasks required to live well with the
disease."
"Those affected by kidney disease must take an active role in their care,
gain information, and build self-management skills to achieve optimal
health outcomes.
Self-management skills for those with kidney disease include
communicating effectively, developing an active partnership with
the care team, taking part in self-care activities (including making
dietary changes and increasing physical activity), and adherence to
medication and treatment regimens."
"Self-management is associated with improved health, including lower
self-reported pain and fatigue, improved healthcare utilization and
physician communication, decreased emergency room visits, and lower
hospitalization rates."
Thus, these benefits and lower costs can prove important and it is
essential for patients to go through community-based self-
management programs since these community programs serve as a
resource for those with kidney disease to help build kidney-disease
self-management skills.
Sources:
1)https://pubmed.ncbi.nlm.nih.gov/30950679/
2)https://www.kidney.org/sites/default/files/v41b_a4.pdf
Method 2: Telehealth or Telemedicine

remote consultations and follow-up care through telemedicine can reduce the need for in-
person visits and lower costs.
This involves the use of technology, such as video conferencing, to
connect patients with healthcare providers remotely. This can be a cost-
effective way to provide palliative care, especially for patients in remote
or underserved areas.
Remote consultations and follow-up care through telemedicine can
reduce the need for in-person visits and lower costs.
Source:
1)https://journals.lww.com/cjasn/pages/articleviewer.aspx?year=2021

&issue=12000&article=00005&type=Fulltext
2)https://www.liebertpub.com/doi/abs/10.1089/jpm.2020.0647
Method 3: Home-based care

Home-based care providing care in the patient's home can be less
expensive than inpatient care, and also allows the patient to be in a familiar
and comfortable environment.
International studies suggest that home dialysis is effective and safe;
these countries include France, Canada, Australia, and New Zealand.
Currently in America, "fewer than 15% of patients receive home dialysis
in the US, in part due to regulatory issues and lack of infrastructure that
limit innovation in home dialysis care delivery" such as the system of
Medicare.
There are limited US evidence for assisted home dialysis, although
recently in 2020 a study confirmed that assisted home dialysis is
operationally feasible in the United States.
The Federal government already recognizes that home dialysis
could improve patient outcomes and lower costs for patients with
early stage renal disease. Hopefully in the future, with more
evidence based studies with US data will allow the US to
incorporate and optimize assisted home dialysis.
Source: 1) https://effectivehealthcare.ahrq.gov/get-
involved/nominated-topics/home-dialysis-ESKD
Care-coordination this involves working with a team of healthcare

providers to coordinate care for the patient. This can help ensure that the
patient receives appropriate care and can help reduce costs by avoiding
unnecessary tests and treatments.
greatly reduced the escalation in hospital use and costs commonly seen
in the final months of life.
The results are similar in magnitude to those demonstrated in previously
published controlled studies of community-based PC and home-based
primary care and demonstrate a reasonable return on investment for
Source: 1)
https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.14354
Appendix:
A case of a man that made his own homemade dialysis machine out of
necessity: https://www.medgadget.com/2013/01/crafty-chinese-man-with-
kidney-disease-lives-on-homemade-dialysis-machine.html

Youtube video of this case:
Do-It-Yourself dialysis keeps man alive

New technologies in development
1. Bioengineered kidneys
New technologies currently under development to help solve some of these
problems include bio-engineered kidneys, miniaturized artificial kidneys,
stem cell therapy, and AI.
The main treatments currently available for kidney disease are dialysis
and kidney transplants. Both of these methods have some clear
disadvantages.
Dialysis takes significant time out of people's weeks, with the
procedure needing to be done several times a week.
Transplants are a good solution but only when they are available.
The demand for kidneys far exceeds the number of donors. Also,
none of these methods are cheap.
A DALL-E Generated Image of a Bio-engineered Kidney
Just 17,000 of the 100,000 Americans in need of a kidney transplant

each year get one. Bioengineered kidneys are intended to get around

the lack of kidney donors.
Simply put, research is being done to build bioengineered kidneys
that can then be transplanted. While building a full kidney has not
been done yet, building kidney tissue has been found to be feasible.
One of the main obstacles in the development of bioengineered kidneys

is that kidneys are made of more than 20 different types of cells.
Building a large enough quantity of this many cells is made even more
difficult by the fact that these cells lose their specialized abilities after
being isolated and cultured.
However, most of the cells are derived from 3-4 main types of cells,
and developments in cellular reprogramming have solved many of
the obstacles in creating large quantities of these more specialized
cells. Creating a fully functional bioengineered kidney is achievable,
but still a long way away.
2. Miniaturized Artificial Kidney

Also under development are miniaturized artificial kidneys. Unlike the
bioengineered kidneys, the miniaturized artificial kidneys are more like small
wearable dialysis machines.
This would stop people from needing to take time out of their days to do
their dialysis treatment at home or at a medical center. The device
would be fully automated, but would have some cons. The wearable
device would need battery changes and more importantly frequent
dialysate cartridge changes (every seven hours).
Also under development are implanted artificial kidneys, which would
not require as much maintenance. These would be made of silicon and
act as a solution in between a bioengineered kidney and a miniaturized
dialysis machine.

DALL-E Generated Image of a Miniaturized Artificial Kidney
3. AI
AI's role in solving problems related to kidney disease is different to the
other new technologies discussed. AI is not a new treatment or method to
actually stop kidney disease, but a tool that can be used by medical
professionals to help make better decisions about kidney disease treatment.
An incredible amount of clinical data exists, but it is difficult to process
and even more difficult to apply anything learned from it to the
treatment of one specific patient.
By having access to and the ability to process all of this clinical
data, AI can help provide more information to doctors. AI can alert
doctors about potential kidney disease in a patient, and then use
image processing technology to diagnose the exact issue.
From here, AI can compare a specific patients disease to previously
collected data to see which treatments are most effective, and which
would be most appropriate for a specific patient.
By taking and analyzing clinical data from other cases, AI
technology can even predict how the disease will evolve in a
patient, providing further information for doctors.

DALL-E Generated Image of an AI Kidney
4. Stem cell
One of the major focuses in today's medical research is stem cell therapy.
Stem cells are the only types of cells that can generate other types of cells
such as other stem cells or other cells with special functions.
Research is being done on how stem cells can be transplanted to

actually repair a kidney. Not replace it, or provide an alternative to act
as a kidney, but actually repair damaged or diseased kidney.
Some of the most flexible stem cells are embryonic stem cells, however
the use of ESCs has faced controversy because they are derived from
4-5 day old human embryos. ESCs can generate every other type of cell
and more stem cells. An alternative to ESCs are induced pluripotent
stem cells.
These can be generated from adult cells, making them less
controversial. Their ability to create kidney organoids has been proven,
but not all ISPCs have the same ability to differentiate, since they
depend on the memory of their parent cells.
Most medical trials have used mesenchymal stromal cells, which
can be sourced from bone marrow, adipose tissue, or umbilical
cords. A disadvantage of these cells is that their differentiation

abilities deteriorate with donor age. MSCs have been found to be
one of the most effective types of stem cells for repairing the
kidney.
Source List:
1)Artificial Kidneys 1
Link/Source: The Wearable Artificial Kidney
Research is being done on building a miniaturized artificial kidney, or a
portable dialysis machine. This would make life easier for dialysis patients
who would no longer need to take the time to go to a medical center for
dialysis, instead they would have a small wearable device that could do the
treatment anywhere. This would significantly improve the lives of 10s of
millions of people who need or are currently going through dialysis
treatment. Wearable devices would be automatic and would only require
periodic battery and cartridge changes, which could be done easily by the
patient. Implanted artificial kidneys are also being developed, and unlike the
wearable devices, they would not require battery or cartridge changes. None
of these devices are currently available.
2)Bioengineered Kidneys
Link/Source: THE BIOENGINEERED KIDNEY - SCIENCE OR SCIENCE
FICTION?
Text: One of the best solutions for treating kidney damage is replacing the
donors to go around. A bioengineered kidney would allow transplants to

happen without waiting for a donor. Part of the difficulty with developing an
bioengineered kidney comes from the fact that there are over 20 different
types of cells in kidneys. Having a sufficient quantity of each type of cell and
then actually creating a functioning bioengineered kidney that can be
transplanted into a human is an extremely difficult task.
3)Artificial Kidneys 2
Link/Source:
The future of the artificial kidney: moving towards wearable and
miniaturized devices - PubMed
Text: Dialysis researchers are working on creating easily transportable or
wearable artificial kidneys which could significantly reduce the QOL impact
on dialysis patients and also make it a cheaper treatment,
4)AI
Link/Source:
Role of Artificial Intelligence in Kidney Disease
Text: AI can be used to detect disease earlier, diagnose, and guide

treatment. This is not so much a revolutionary new treatment that will cure
kidney disease, but a tool that can help doctors catch kidney disease earlier,
and help them make decisions on the best treatment path. It can also be
used to predict how the disease will evolve in a patient, giving doctors
further information.
5)Stem Cell 1
Link/Source:
Current advances of stem cell-based therapy for kidney diseases
Text: Stem Cell therapy = Promising regenerative medicine. Current drugs
only slow down kidney disease. Stem cell therapy has the potential to
actually reverse kidney disease and repair damage. Currently, the only
solutions to late stage kidney disease are transplants (limited donors), or
kidney
is made up of so many different cell types, it is difficult to reconstruct.
6)Stem Cell 2
Link/Source:
Kidney Disease
Text: Harvard Stem Cell Institute is developing stem cell therapies that
could help repair kidney damage. This would reduce the need for transplants
or dialysis. Mesenchymal stem cells are the stem cells responsible for
protecting the kidney from injury and helping to heal it.

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Kidney Physiology and Biophysics

Thursday, February 2, 2023 1:36 PM

Nephrology - Kidney Physiology Overview

Renal Physiology Nephrology and Urology

Kidney Physiology and Biophysics Page 2

Kidney Physiology and Biophysics Page 3

Circulatory System and Blood Supply

Kidney Physiology and Biophysics Page 4

Kidney Physiology and Biophysics Page 5

Kidney Physiology and Biophysics Page 6

Acute Kidney Injury

Kidney Physiology and Biophysics Page 7

Figure 5. During hemodialysis, blood is pumped through a dialyzer [2].

Click Here to Learn More about Low-Cost Dialysis Options

Kidney Physiology and Biophysics Page 8

Kidney Physiology and Biophysics Page 9

How Hemodialysis Works

<-- Catheter Placement

Living With CKD Page 10

Regular hemodialysis treatments: A person undergoing hemodialysis typically

"Living With Kidney Disease" CityNews, Canada

Living With CKD Page 11

Living With CKD Page 12

Compounding Risks Associated with Kidney Disease

Living With CKD Page 13

Www.cdc.gov, 10 Mar. 2021,

- Diagnosis and Treatment - Mayoclinic.org,

Kidney Disease Statistics for the United States | NIDDK (nih.gov)

Living With CKD Page 14

Living With CKD Page 15

Name of Specialist: Madhu Vijayan

Expand acronym in first use CKD

Living With CKD Page 16

Living With CKD Page 17

Racial Coefficients Improving Nephrological Care

Racial Coefficients Deteriorating Nephrological Care

Chronic Kidney Disease Epidemiology Collaboration

Modification of Diet in Renal Disease

Racial disparities in nephrological care Page 18

Racial disparities in nephrological care Page 19

HOW RACE/SOCIOECONMIC STATUS CONTRIBUTES TO HEALTH

DISPARITY IN TREATMENTS RECIEVED

Racial disparities in nephrological care Page 20

Racial disparities in nephrological care Page 21

Studies Siding with Racial Coefficients to Be Used in eGFR Equations

Racial disparities in nephrological care Page 22

Racial disparities in nephrological care Page 23

Racial disparities in nephrological care Page 24

Transplantation Direct, U.S. National Library of Medicine,

Racial disparities in nephrological care Page 25

Racial disparities in nephrological care Page 26

Categorization of CAKUT tends to be dependent on the specific type of reno-anomaly, as follows:

Anomalies of renal position

Anomalies of renal number

Table providing an overview of variations of CAKUT:

Environmental and Epigenetic Factors

potentially increase the risk of CAKUT.

Ultrasound of fetus in amniotic fluid [1]

-Chronic Kidney Disease

Treatment of Pediatric Vesicoureteral Reflux (VUR)

Treatment for UTIs include medication: Trimethoprim and sulfamethoxazole, Fosfomycin,

Kidney transport Eligibility

Innovations in Kidney Paired Donation