Kidney Transplantation

When your health care provider makes the diagnosis of end-stage renal disease, he or she will discuss your treatment options. Whether kidney transplantation is an option for you depends on your specific situation. If your health care provider thinks you may be eligible for a transplant, you will learn about the pros and cons of this treatment. If you are a potential candidate, you will undergo a thorough medical evaluation. In the meantime, you will be treated with dialysis. Kidney transplantation is replacement of nonworking kidneys with a healthy kidney from another person (the donor). he healthy kidney (the !graft!) takes over the functions of your nonworking kidneys. "ou can live normally with only one kidney as long as it functions properly. he transplantation itself is a surgical operation. he surgeon places the new kidney in your abdomen and attaches it to the artery that supplied blood to one of your kidneys and to the vein that carries blood away from the kidney. he kidney is also attached to the ureter, which carries urine from the kidney to the bladder. "our own kidneys are usually left in place unless they are causing you problems, such as infection. #very operation has risks, but kidney transplantation is not a particularly difficult or complicated operation. It is the period after the surgery that is most critical. "our medical team will watch very carefully to make sure that your new kidney is functioning properly and that your body is not re$ecting the kidney. Are you eligible for a transplant? %efore you can receive a kidney transplant, you must undergo a very detailed medical evaluation.

his evaluation may take weeks or months and re&uire several visits to the transplant center for tests and e'aminations. he purpose of this thorough evaluation is to test whether you would benefit from a transplant and can withstand the rigors of the surgery and antire$ection medications and the ad$ustment to a new organ.

"our medical team, which includes a nephrologist, a transplant surgeon, a transplant coordinator, a social worker, and others, will conduct a series of interviews with you and your family members.

"ou will be asked many &uestions about your medical and surgical history, the medications you take and have taken in the past, and your habits and lifestyle. It will seem like they ask every imaginable &uestion at least twice( It is important that they know every detail about you that could bear on a future transplant. hey also want to make sure you are mentally prepared for following the necessary medication regimen.

"ou will also have a complete physical e'amination. )ab tests and imaging studies complete the evaluation.

"our blood and tissue will be typed so that you can be matched to a donor kidney. his significantly lessens the chance of re$ection. "ou will have blood and urine tests to monitor your creatinine level, other organ functions, and electrolyte levels. "ou will have '-rays, ultrasounds, * +,-I scans, and other imaging tests as needed to make sure your other organs are healthy and functioning.

.ny of the following conditions significantly increase your chance of re$ecting the new kidney and may make you ineligible for transplant/

.ctive cancer 0I1 infection 2erious heart or lung disease 3ositive results for hepatitis * 2evere infection

3otential kidney donors also must be in good health and undergo a thorough medical evaluation. If you are considered eligible for a transplant, every effort will be made to find a donor among your family members (who are most likely to match) and friends. If no suitable donor can be found, your name will be added to the waiting list for a donor kidney.

his list is administered by the 4rgan 3rocurement and ransplantation 5etwork, which maintains a centrali6ed database of everyone waiting for a transplant and of living donors. 43 * is run by the 7nited 5etwork for 4rgan 2haring, a private nonprofit organi6ation. #very new kidney that becomes available is tested and checked against this list to find the most perfect match.

2ince medication to prevent re$ection is so effective, donors do not need to be genetically similar to their recipient. ,ost donated kidneys come from deceased donors, however the utili6ation of living donors in the 7nited 2tates is on the rise. In 899:, ;<= of donated kidneys were from living donors.>;? his varies by country/ for e'ample, only @= of kidneys transplanted during 899: in 2pain came from living donors.>A?

[edit] Living donors

,ore than one in three donations in the 7K is now from a live donor>:? and almost one in three in Israel.><? he percentage of transplants from living donors is increasing. 3otential donors are carefully evaluated on medical and psychological grounds. his ensures that the donor is fit for surgery and has no disease which brings undue risk or likelihood of a poor outcome for either the donor or recipient. he psychological

assessment is to ensure the donor gives informed consent and is not coerced. In countries where paying for organs is illegal, the authorities may also seek to ensure that a donation has not resulted from a financial transaction. In the 7K, the 0uman issue .ct 899; (0 .) dictated that donors must prove a familial or long term relationship or enduring friendship, for instance by providing photographs of themselves together spread over a period of time, or a birth or wedding certificate. 3urely altruistic donation to strangers has recently been accepted by the 0uman issue .uthority in the 7nited Kingdom, and as of Becember 899< only four people had been given permission to do this under the 0 .. he decision must be approved by a panel, whereas the typical donation based on relationship is re&uired only to go through an e'ecutive.>C? here is good evidence that kidney donation is not associated with long term harm to the donor.>D? 2o called !daisy chain! transplants in the 72 involve one altruistic donor who donates a kidney to someone who has a family member willing to donate, who isnEt a match. hat family member then donates to a recipient who is a match. his !chain! can be continued with several more pairs of donors+recipients.>F9? raditionally, the donor procedure has been through a single incision of ;G< inches (F9GFC cm), but live donation is being increasingly performed by laparoscopic surgery. his reduces pain and accelerates recovery for the donor. 4perative time and complications decreased significantly after a surgeon performed FA9 cases. )ive donor kidney grafts tend to perform better than those from deceased donors.>FF? 2ince the increase in the use of laparoscopic surgery, the number of live donors has increased. .ny advance which leads to a decrease in pain and scarring and swifter recovery has the potential to boost donor numbers. In Hanuary 899D, the first allrobotic kidney transplant was performed at 2aint %arnabas ,edical *enter through a two-inch incision. In the following si' months, the same team performed eight more robotic-assisted transplants.>F8? In 899; the IB. approved the *edars-2inai 0igh Bose I1IJ therapy which reduces the need for the living donor to be the same blood type (.%4 compatible) or even a tissue match.>F@?>F;? he therapy reduced the incidence of the recipientEs immune system re$ecting the donated kidney in highly sensiti6ed patients.>F;? In 899D at the Hohns 0opkins ,edical *enter, a healthy kidney was removed through the donorEs vagina. 1aginal donations promise to speed recovery and reduce scarring. >FA? he first donor was chosen as she had previously had a hysterectomy.>F:? he e'traction was performed using natural orifice transluminal endoscopic surgery, where an endoscope is inserted through an orifice, then through an internal incision, so that there is no e'ternal scar. he recent advance of single port access surgery re&uiring only one entry point at the navel is another advance with potential for more fre&uent use.

[edit] Organ trade

,ain article/ 4rgan trade In the developing world some people sell their organs. 2uch people are often in grave poverty,>F<? or e'ploited by salespersons. 3eople travelling to make use of such kidneys, sometimes known as !transplant tourists!, are not looked upon favorably by organi6ations such as the 72 5ational Kidney Ioundation. hese patients may have increased complications due to poor infection control and lower medical and surgical standards. 4ne surgeon has said organ trade could be legali6ed in the 7K to prevent such tourism, but this is not seen by the 5ational Kidney -esearch Iund as the answer to a deficit in donors.>FC?

[edit] Deceased donors

Beceased donors can be divided in two groups/

%rain-dead (%B) donors Bonation after *ardiac Beath (B*B) donors

.lthough brain-dead (or !beating heart!) donors are considered dead, the donorEs heart continues to pump and maintain the circulation. his makes it possible for surgeons to start operating while the organs are still being perfused. Buring the operation, the aorta will be cannulated, after which the donorEs blood will be replaced by an ice-cold storage solution, such as 7W (1iaspan), 0 K, or 3erfade'. Bepending on which organs are transplanted, more than one solution may be used simultaneously. Bue to the temperature of the solution, and since large amounts of cold 5a*l-solution are poured over the organs for a rapid cooling, the heart will stop pumping. !Bonation after *ardiac Beath! donors are patients who do not meet the brain-dead criteria but, due to the small chance of recovery, have elected via a living will or through family to withdraw support. In this procedure, treatment is discontinued (mechanical ventilation is shut off). .fter a time of death has been pronounced, the patient is rushed to the operating room where the organs are recovered. 2torage solution is flushed through the organs. 2ince the blood is no longer being circulated, coagulation must be prevented with large amounts of anti-coagulation agents such as heparin. 2everal ethical and procedural guidelines must be followedK most importantly, the organ recovery team should not participate in the patientEs care in any manner until after death has been declared.

In most cases the barely functioning e'isting kidneys are not removed, as this has been shown to increase the rates of surgical morbidities. herefore the kidney is usually placed in a location different from the original kidney, often in the iliac fossa, so it is often necessary to use a different blood supply/

he renal artery of the kidney, previously branching from the abdominal aorta in the donor, is often connected to the e'ternal iliac artery in the recipient. he renal vein of the new kidney, previously draining to the inferior vena cava in the donor, is often connected to the e'ternal iliac vein in the recipient.

here is disagreement in surgical te'tbooks regarding which side of the recipientLs pelvis to use in receiving the transplant. *ampbellEs 7rology (8998) recommends placing the donor kidney in the recipientLs contralateral side (i.e. a left sided kidney would be transplanted in the recipientEs right side) to ensure the renal pelvis and ureter are anterior in the event that future surgeries are re&uired. In an instance where there is doubt over whether there is enough space in the recipientLs pelvis for the donorEs kidney the te'tbook recommends using the right side because the right side has a wider choice of arteries and veins for reconstruction. 2mithEs 7rology (899;) states that either side of the recipientEs pelvis is acceptable, however the right vessels are Mmore hori6ontalN with respect to each other and therefore easier to use in the anastomoses. It is unclear what is meant by the words Mmore hori6ontalN. JlenEs 7rological 2urgery (899;) recommends putting the kidney in the contralateral side in all circumstances. 5o reason is e'plicitly put forth however one can assume the rationale is similar to that of *ampbellEs- to ensure the renal pelvis and ureter are most anterior in the event that future surgical correction are necessary.

he transplant surgery takes about three hours.>89? he donor kidney will be placed in the lower abdomen and its blood vessels connected to arteries and veins in the recipientEs body. When this is complete, blood will be allowed to flow through the kidney again. he final step is connecting the ureter from the donor kidney to the bladder. In most cases, the kidney will soon start producing urine. Bepending on its &uality, the new kidney usually begins functioning immediately. )iving donor kidneys normally re&uire @GA days to reach normal functioning levels, while cadaveric donations stretch that interval to <GFA days. 0ospital stay is typically for ;G< days. If complications arise, additional medications (diuretics) may be administered to help the kidney produce urine. Immunosuppressant drugs are used to suppress the immune system from re$ecting the donor kidney. hese medicines must be taken for the rest of the patientEs life. he most common medication regimen today is a cocktail of tacrolimus, mycophenolate, and prednisone. 2ome patients may instead take cyclosporine, sirolimus, or a6athioprine. *yclosporine, considered a breakthrough immunosuppressive when first discovered in the FDC9s, ironically causes nephroto'icity and can result in iatrogenic damage to the newly transplanted kidney. %lood levels must be monitored closely and if the patient seems to have declining renal function, a biopsy may be necessary to determine whether this is due to re$ection or cyclosporine into'ication.

Types of rejection
[edit] Hyperacute rejection
0yperacute re$ection is a complement-mediated response in recipients with pree'isting antibodies to the donor (for e'ample, .%4 blood type antibodies). 0yperacute re$ection occurs within minutes after the transplant and must be immediately removed to prevent a severe systemic inflammatory response. -apid agglutination of the blood occurs. his is a particular risk in kidney transplants, and so a prospective cytoto'ic crossmatch is performed prior to kidney transplantation to ensure that antibodies to the donor are not present. 0yperacute re$ection is analogous to a blood transfusion reaction as it is a humoral-mediated immune response. Ior other organs, hyperacute re$ection is prevented by transplanting only .%4-compatible grafts. 0yperacute re$ection is not significant in liver allografts and cellular transplants because these tissues have remarkable regenerative abilities. 0yperacute re$ection is the outcome of 'enotransplanted organ in non-immunosuppressed recipients.

[edit] Acute rejection

,ain article/ 0istocompatibility .cute re$ection may begin as early as one week after transplantation (as opposed to hyperacute re$ection, which is immediate). he risk of acute re$ection is highest in the first three months after transplantation. 0owever, acute re$ection can also occur months to years after transplantation. . single episode of acute re$ection is not a cause for concern if recogni6ed and treated promptly, and rarely leads to organ failure. %ut recurrent episodes are associated with chronic rejection (see below).

.cute re$ection occurs to some degree in all transplants (e'cept those between identical twins) unless the immune response is altered through the use of immunosuppressive drugs. It is caused by mismatched 0)., which are present on all cells of the body. here are a large number of different alleles of each 0)., so a perfect match between all 0). in the donor tissue and the recipientEs body is e'tremely rare. issues such as the kidney or the liver which are highly vasculari6ed (rich in blood vessels), are often the earliest victims of acute re$ection. In fact, episodes of acute re$ection occur in around F9-@9= of all kidney transplants, and A9 to :9= of liver transplants. Bamage to the endothelial lining of blood vessels is an early predictor of irreversible acute transplant re$ection. he reason that acute re$ection usually begins one week after transplantation is the delay in activation of the involved -cells. 4ften transplanted organs are ac&uired from a cadaveric source (e.g. trauma victim) and as a result of ischemia and+or trauma are already in a state of inflammation. he inflammatory response results in donorderived dendritic cells migrating to the secondary lymphoid tissues (e.g. lymph node) of the recipient. here they present self-antigen derived from the donated organ to recipient -cells. -cells that interact with allogeneic 0). comple'es have the potential to become activated and develop an immune response against the F.) selfpeptide, 8.) the allogeneic 0). molecule itself, or @.) a combination of both. hese -cells must differentiate before the alloreaction begins and the tissue is re$ected. he alloreactive -cells cause cells in the transplanted tissue to lyse, or produce cytokines that cause necrosis of the transplanted tissue. his process can take days, or even weeks to manifest. he first successful organ transplant, performed in FDA; by Br. Hoseph ,urray, was successful because the donor and recipient were identical twins, and therefore no cell-mediated responses could be generated against the transplanted organ. he diagnosis of acute re$ection relies on clinical data, including patient signs and symptoms, laboratory testing and ultimately a tissue biopsy. he biopsy is interpreted by a pathologist who notes changes in the tissue that suggest re$ection. Jenerally the pathologist looks for three main histological features. Iirst, the presence of -cells infiltrating the transplanted tissueK these may be accompanied by a heterogeneous collection of other cell types including eosinophils, plasma cells and neutrophils. ( he proportions of these cell types may be helpful in diagnosing the e'act type of re$ection.) 2econdly, evidence of structural in$ury to the transplanted tissueK the characteristics of this in$ury will depend on the type of tissue being transplanted. )astly, in$ury to the blood vessels in the transplanted tissue. -ecent technological advancements have led to genetic e'pression testing in the form of a blood test. hese tests, such as .llo,ap ,olecular #'pression esting have a high negative predictive value help manage the .*- re$ection in transplant patients. hese genetic e'pression tests are specific to the transplanted organ type.

[edit] hronic rejection

he term !chronic re$ection! was initially a term used to describe a long-term loss of function in transplanted organs, associated with fibrosis of the internal blood vessels of the transplanted tissue. %ut this pathology is now termed chronic allograft vasculopathy. he term chronic rejection is reserved for cases of transplant re$ection where the re$ection is due to a poorly understood chronic inflammatory and immune response against the transplanted tissue.

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Why Are the Kidneys So Important?

,ost people know that a ma$or function of the kidneys is to remove waste products and e'cess fluid from the body. hese waste products and e'cess fluid are removed through the urine. he production of urine involves highly comple' steps of e'cretion and reabsorption. his process is necessary to maintain a stable balance of body chemicals. he critical regulation of the bodyEs salt, potassium and acid content is performed by the kidneys. he kidneys also produce hormones that affect the function of other organs. Ior e'ample, a hormone produced by the kidneys stimulates red blood cell production. 4ther hormones produced by the kidneys help regulate blood pressure and control calcium metabolism. he kidneys are powerful chemical factories that perform the following functions/

remove waste products from the body remove drugs form the body balance the bodyEs fluids release hormones that regulate blood pressure produce an active form of vitamin B that promotes strong, healthy bones control the production of red blood cells

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Where Are the Kidneys and How Do They Function?

here are two kidneys, each about the si6e of a fist, located on either side of the spine at the lowest level of the rib cage. #ach kidney contains up to a million functioning units called nephrons. . nephron consists of a filtering unit of tiny blood vessels called a glomerulus attached to a tubule. When blood enters the glomerulus, it is filtered and the remaining fluid then passes along the tubule. In the tubule, chemicals and water are either added to or removed from this filtered fluid according to the bodyEs needs, the final product being the urine we e'crete. he kidneys perform their life-sustaining $ob of filtering and returning to the bloodstream about 899 &uarts of fluid every 8; hours. .bout two &uarts are removed from the body in the form of urine, and about FDC &uarts are recovered. he urine we e'crete has been stored in the bladder for anywhere from F to C hours.

!hat do the "idneys do?

he kidneys are bean-shaped organs, each about the si6e of a fist. hey are located near the middle of the back, $ust below the rib cage, one on each side of the spine. he kidneys are sophisticated reprocessing machines. #very day, a personLs kidneys process about 899 &uarts of blood to sift out about 8 &uarts of waste products and e'tra water. he wastes and e'tra water become urine, which flows to the bladder through tubes called ureters. he bladder stores urine until releasing it through urination.

he kidneys remove wastes and water from the blood to form urine. 7rine flows from the kidneys to the bladder through the ureters. Wastes in the blood come from the normal breakdown of active tissues, such as muscles, and from food. he body uses food for energy and self-repairs. .fter the body has taken what it needs from food, wastes are sent to the blood. If the kidneys did not remove them, these wastes would build up in the blood and damage the body. he actual removal of wastes occurs in tiny units inside the kidneys called nephrons. #ach kidney has about a million nephrons. In the nephron, a glomerulusOwhich is a tiny blood vessel, or capillaryOintertwines with a tiny urine-collecting tube called a tubule. he glomerulus acts as a filtering unit, or sieve, and keeps normal proteins and cells in the bloodstream, allowing e'tra fluid and wastes to pass through. . complicated chemical e'change takes place, as waste materials and water leave the blood and enter the urinary system.

In the nephron (left), tiny blood vessels intertwine with urine-collecting tubes. #ach kidney contains about F million nephrons. .t first, the tubules receive a combination of waste materials and chemicals the body can still use. he kidneys measure out chemicals like sodium, phosphorus, and potassium and release them back to the blood to return to the body. In this way, the kidneys regulate the bodyLs level of these substances. he right balance is necessary for life.

In addition to removing wastes, the kidneys release three important hormones/

erythropoietin, or #34, which stimulates the bone marrow to make red blood cells renin, which regulates blood pressure calcitriol, the active form of vitamin B, which helps maintain calcium for bones and for normal chemical balance in the body

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!hat is renal function?

he word MrenalN refers to the kidneys. he terms Mrenal functionN and Mkidney functionN mean the same thing. 0ealth professionals use the term Mrenal functionN to talk about how efficiently the kidneys filter blood. 3eople with two healthy kidneys have F99 percent of their kidney function. 2mall or mild declines in kidney function Oas much as @9 to ;9 percentOwould rarely be noticeable. Kidney function is now calculated using a blood sample and a formula to find the estimated glomerular filtration rate (eJI-). he eJI- corresponds to the percent of kidney function available. he section MWhat medical tests detect kidney diseasePN contains more details about the eJI-. 2ome people are born with only one kidney but can still lead normal, healthy lives. #very year, thousands of people donate one of their kidneys for transplantation to a family member or friend. Ior many people with reduced kidney function, a kidney disease is also present and will get worse. 2erious health problems occur when people have less than 8A percent of their kidney function. When kidney function drops below F9 to FA percent, a person needs some form of renal replacement therapyOeither blood-cleansing treatments called dialysis or a kidney transplantOto sustain life. KIDNEYS:
Two bean shaped organs (about 10 to 11 cms X 5 to cms! one "n each #o"n on e"ther s"de o$ the bac% bone& connected to the b#adder b' two tubes (ureters!( K"dne's rece")e about *5+ o$ the b#ood pumped dur"ng each heart beat( ,bout -+ o$ peop#e are born w"th on#' one $unct"on"ng %"dne'( .an' o$ them are not aware that the' ha)e on#' one %"dne'& s"nce one %"dne' (or e)en #ess than one who#e %"dne'! "s ade/uate to #ead a norma# #"$e( Each %"dne' has a b#ood )esse# (0ena# ,rter'! br"ng"ng the b#ood to the %"dne' to be processed and another b#ood )esse# (0ena# 1e"n! ta%"ng the processed b#ood bac% to the heart( Dur"ng

such process"ng man' chem"ca# waste mater"a#s are remo)ed 2 $"#tered $rom the b#ood and added to the ur"ne to be e#"m"nated $rom the bod'( ,t the same t"me& man' essent"a# hormones and chem"ca#s are added b' the %"dne's to the b#ood as we##(

345 D4 KIDNEYS 540K6

Each kidney has millions of tiny filters called 'Nephrons.' Renal artery brings the blood to pass through these nephrons. As the blood passes through, it is filtered. As much as 180 of fluid !ith all the essential and non" essential chemicals are filtered per day. Almost 1#8 of fluid and the essential chemicals and electrolytes are returned to the blood per day by the 'tubule'. $n addition tubules and other cells synthesi%e and add &arious essential chemicals and hormones to the blood. 'n!anted chemicals and those essential chemicals !hich are present in the blood in e(cess, are left in the ) of fluid to be e(creted as urine. *ut such filtering and selecti&ely reabsorbing certain substances is only on of the many functions of the kidneys. +or a better understanding of the other functions of the kidney please read ',hat do kidneys do-'

-( 5ater content o$ the bod': 7or appropr"ate $unct"on o$ a## the t"ssues and organs o$ the bod'& the water content o$ the bod' shou#d be norma#( 5hen the water content o$ the bod' "ncreases the organs and t"ssues get 8water #ogged89 and when the water content "s #ow the t"ssues and organs are 8deh'drated8( :oth these abnorma#"t"es ad)erse#' a$$ect the bod' and causes ma#$unct"on o$ )ar"ous organs and t"ssues( K"dne's constant#' mon"tor the water content o$ the bod' and ma"nta"n at norma# #e)e#s to the e;tent $eas"b#e b' #"m"t"ng or "ncreas"ng the e#"m"nat"on o$ water $rom the bod' "n the $orm o$ ur"ne( 5hen the %"dne's are d"seased& such a regu#ator' $unct"on o$ the %"dne's to ensure that the 8hum"d"t'8 (3'drat"on! o$ the "nterna# en)"ronment "s ma"nta"ned& "s "mpa"red( <onse/uent#'& more $#u"d cou#d be #ost )"a ur"ne e)en when the bod' "s deh'drated& $urther worsen"ng the $unct"ons o$ a## organs and t"ssues9 or more $#u"d "s reta"ned due to decreas"ng ur"ne )o#ume& and cause d's$unct"on o$ organs and t"ssues as the' get water #ogged( Such e;cess retent"on o$ water causes swe##"ng o$ the bod' (#egs& arms& $ace and abdomen!( Such swe##"ng "s ca##ed edema( S"nce heart "s the organ to pump the $#u"d (#'mph and b#ood! around& such e;cess $#u"d retent"on cou#d a#so cause heart $a"#ure (congest")e heart $a"#ure!(

=( Interna# chem"ca# en)"ronment: 7or proper $unct"on o$ )ar"ous organs and t"ssues& the "nterna# chem"ca# en)"ronment need to be mon"tored& regu#ated and ma"nta"ned w"th"n a narrow range o$ )ar"ab"#"t'( Some o$ the chem"ca#s (,c"d>:ase& e#ectro#'tes! and the narrow ranges the' need to be ma"nta"ned "n are: S4DI?. A4T,SSI?. <3@40IDES :I<,0:4N,TE <,@<I?. .,CNESI?. A34SA340?S ?0I< ,<ID p3 <0E,TININE :?N :#ood ?rea N"trogen! 1-5 T4 1=5 mE/2@ -(5 T4 5(5 mE/2@ 100 to 110 mE/2@ *= to * mE/2@

B( to 10 mgs2d# 1( to *(= mgs2d# -(0 to 5(0 mgs2d# *(5 to (0 mgs2d# D(= 0(B T4 1(= .CS2D@ 15 to *0 mgs2d#

All o&er"the"counter and prescription medications, herbal and natural medications enter the blood stream as &arious chemicals. As the body metaboli%es those substances, the resulting metabolic products also enter the blood. .he le&els of the original medications and of their metabolic products need to be kept in a narro! and specific range. +ailure to regulate those le&els !ill alter the chemical en&ironment and cause organ to(icity.
K"dne's are the pr"mar' organs that mon"tor& regu#ate and ma"nta"n such a de#"cate and $rag"#e "nterna# chem"ca# en)"ronment( The' do th"s b' add"ng or remo)"ng chem"ca#s $rom the b#ood( ,t other t"mes the' add or remo)e hormones to and $rom the b#ood( For example& "$ the <a#c"um #e)e# "s #ow& %"dne's con)ert pro>)"tam"n D to act")e )"tam"n D( (7or pract"ca# purposes& the on#' organ that generates the act")e )"tam"n D "s the %"dne'!( The act")e )"tam"n D then trans$ers ca#c"um $rom the bone to the b#ood( It a#so ma%es the "ntest"nes absorb more ca#c"um $rom the $ood and the b#ood ca#c"um #e)e# "s thus ma"nta"ned on an ongo"ng bas"s( 5hen the %"dne's are a$$ected th"s mechan"sm su$$ers and the b#ood #e)e#s o$ ca#c"um cou#d decrease (3'poca#caem"a! caus"ng other comp#"cat"ons(

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