Point-of-Care Ultrasound for the Diagnosis of Congestive Kidney Due to Severe Acidemia: A Case Report.

A 51-year-old woman with mitochondrial myopathy and congestive heart failure with reduced left ventricular ejection fraction was admitted due to loss of appetite and progressive frailty. She presented with acute kidney injury (AKI) and severe acidemia. Given her medical history and physical examination (jugular vein distention was not obvious), prerenal causes (hypovolemia/hypotension) of AKI were considered most likely. However, with a significantly elevated N-terminal pro-b-type natriuretic peptide level of 14,700 pg/mL, a congestive kidney was also considered. Bedside echocardiography showed no evidence of low output syndrome, whereas venous excess ultrasound (VExUS) score was assessed as Grade 2 (moderate congestion). In addition to administering fluids for the suspected prerenal causes (hypovolemia/hypotension), sodium bicarbonate was administered suspecting a negative impact of severe acidemia on cardiac function. With the improvement of acidemia and only a small volume of fluid therapy, there was a rapid improvement in AKI with the normalization of the VExUS score. This suggested that the main cause of AKI was congestive kidney. In this case, VExUS helped us make a correct diagnosis of acidemia-induced congestive kidney rather than hypovolemia as a cause of AKI, leading to the appropriate treatment.

Growth-phase dependent morphological alteration in higher plant thylakoid is accompanied by changes in both photodamage and repair rates.

Thylakoid membranes of young leaves consist of grana and stroma lamellae (stroma-grana [SG] structure). The SG thylakoid is gradually converted into isolated grana (IG), almost lacking the stroma lamellae during growth. This morphological alteration was found to cause a reduction in maximum photosynthetic rate and an enhancement of photoinhibition in photosystem II (PSII). In situ microspectrometric measurements of chlorophyll fluorescence in individual chloroplasts suggested an increase of the PSII/PSI ratio in IG thylakoids of mature leaves. Western blot analysis of isolated IG thylakoids showed relative increases in some PSII components, including the core protein (D1) and light-harvesting components CP24 and Lhcb2. Notably, a nonphotochemical quenching-related factor in the PSII supercomplex, PsbS, decreased by 40%. Changes in the high light response of PSII were detected through parameters of pulse-amplitude modulation fluorometry. Chlorophyll fluorescence lifetime indicated an increase of fluorescence quantum yield in IG. A minimal photodamage-repair rate analysis on a lincomycin treatment of the leaves indicated that repair rate constant of IG is slower than that of SG, while photodamage rate of IG is higher than that of SG. These results suggest that IG thylakoids are relatively sensitive to high light, which is not only due to a higher photodamage rate caused by some rearrangements of PS complexes, but also to the retarded PSII repair that may result from the lack of stroma lamellae. The IG thylakoids found among many plant species thus seem to be an adaptive form to low light environments, although their physiological roles still remain unclear.

Significance of structural variation in thylakoid membranes in maintaining functional photosystems during reproductive growth.

Structural variation in the stroma-grana (SG) arrangement of the thylakoid membranes, such as changes in the thickness of the grana stacks and in the ratio between grana and inter-grana thylakoid, is often observed. Broadly, such alterations are considered acclimation to changes in growth and the environment. However, the relation of thylakoid morphology to plant growth and photosynthesis remains obscure. Here, we report changes in the thylakoid during leaf development under a fixed light condition. Histological studies on the chloroplasts of fresh green Arabidopsis leaves have shown that characteristically shaped thylakoid membranes lacking the inter-grana region, referred to hereafter as isolated-grana (IG), occurred adjacent to highly ordered, large grana layers. This morphology was restored to conventional SG thylakoid membranes with the removal of bolting stems from reproductive plants. Statistical analysis showed a negative correlation between the incidences of IG-type chloroplasts in mesophyll cells and the rates of leaf growth. Fluorescence parameters calculated from pulse-amplitude modulated fluorometry measurements and CO2 assimilation data showed that the IG thylakoids had a photosynthetic ability that was equivalent to that of the SG thylakoids under moderate light. However, clear differences were observed in the chlorophyll a/b ratio. The IG thylakoids were apparently an acclimated phenotype to the internal condition of source leaves. The idea is supported by the fact that the life span of the IG thylakoids increased significantly in the later developing leaves. In conclusion, the heterogeneous state of thylakoid membranes is likely important in maintaining photosynthesis during the reproductive phase of growth.