1. Efferent arteriole
Afferent arteriole

2. Filtrate is forced through holes in glomerular capillary walls
Glomerular Filtration
Filtrate is forced through holes in glomerular capillary walls

3. Glomerular capillary:
Internal endothelial cell sieve;
external covering of podocytes

4. Varying resistance to flow controls filtration pressure

5. A-II A-II vasoconstricts predominantly the efferent arteriole
Vasoconstriction increases glomerular pressure and filtration
Afferent arteriole

6. A-II ACEI and ARBs remove A-II effect: efferent arteriole dilates
Glomerular pressure and filtration decrease a little
Afferent arteriole

7. ACEI reduces glomerular pressure and filtration of albumin  remission of nephrotic syndrome due to diabetic nephropathy
eGFR
Ramipril 5mg daily

8. Glomerular pressure and filtration decrease slowly
Low blood pressure and vascular disease reduce pressure and flow into glomerulus
Efferent arteriole
A-II
A-II
Glomerular pressure and filtration decrease slowly
Afferent arteriole

9. A-II ACEI and ARBs remove A-II effect: efferent arteriole dilates
Glomerular pressure and filtration suddenly decrease a lot
Afferent arteriole

10. eGFR
-----lisinopril-----
--ramipril--

11. ACEI and ARBs can be good or bad
: ACEI/ARB reduce pressure and slow decline in GFR. Gradual vascular narrowing 2008: Critical drop in GFR - ACEI/ARB stopped. GFR recovers 2009: Increased glomerular pressure causes proteinuria
eGFR
ACEI and ARBs can be good or bad
for kidney function
lisinopril 20mg od
irbesartan 75mg od
Stop both
Proteinuria
K+ = 7.5
Urea = 22