Charles B., a 43-year-old muscular construction worker, has been feeling unusually tired for several weeks. Occasionally he had felt dizzy and found it increasingly difficult to sleep. More recently he had noticed a burning pain in his lower pack, just below his rib cage, and his urine had darkened. In addition, his feet, ankles, and face seemed swollen. His wife suggested that he consult their family physician about these symptoms.

The physician found that Charles had elevated blood pressure (hypertension) and that the regions of his kidneys were sensitive to pressure. A urinalysis revealed excess protein (proteinuria) and blood (hematuria). Blood tests indicated elevated blood urea nitrogen (BUN), elevated serum protein (hypoproteinemia) concentrations.

The physician told Charles that he probably had chronic glomerulonephritis, an inflammation of the capillaries within the glomeruli of the renal nephrons, and that this was a progressive degenerative disease lacking a cure. Examination of a tiny sample of kidney tissue (biopsy) examined microscopically later confirmed the diagnosis.

In spite of medical treatment and careful attention to his diet, Charles's condition deteriorated rapidly. When it appeared that most of his kidney function had been lost (end-stage renal disease, or ESRD), he was offered artificial kidney treatments (hemodialysis).

To prepare Charles for hemodialysis, a vascular surgeon created a fistula in his left forearm by surgically connecting an artery to a vein. The greater pressure of the blood in the artery that now flowed directly into the vein swelled the vein, making it more accessible.

During hemodialysis treatment, a hollow needle was inserted into the vein of the fistula near its arterial connection. This allowed the blood to flow, with the aid of a blood pump, through a tube leading to the blood compartment of a dialysis solution with a controlled composition. Negative pressure on the dialysate side of the membrane, created by a vacuum pump, increased the movement of fluid through the membrane and entered the dialysate solution. The blood was then returned through a tube to the vein of the fistula.

In order to maintain favorable blood concentrations of waste, electrolytes, and water, Charles had to undergo hemodialysis three times per week, with each treatment lasting three to four hours. During the treatments, he was given an anticoagulant to prevent blood clotting, an antibiotic drug to control infections, and an antihypertensive drug to reduce his blood pressure.

Charles was advised to carefully control his intake of water, sodium, potassium, proteins, and total calories between treatments. He was also asked to consider another option for the treatment of ESRD--a kidney transplant--which could free him from the time-consuming dependence on hemodialysis.

In this surgical procedure, a kidney from a living donor or a cadaver, whose tissues are antigenically similar (histocompatible) to those of the recipient, is placed in the depression on the medial surface of the right or left ilium (iliac fossa). The renal artery and vein of the donor kidney are connected to the recipient's iliac artery and vein, respectively, and the kidney's ureter is attached to the dome of the recipient's urinary bladder. The patient must then remain on immunosuppressant drugs to prevent rejection of the transplant.

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