مدرات البول Flashcards
بسم الله الرحمن الرحيم وبه نستعين
فارج الهم كاشف الغم مجيب دعوة المضطرين رحمن الدنيا والاخرة ورحيمهما ارحمنا رحمة تغنينا بها عن رحمة من سواك
تغنينا: فعل مضارغ مرفوع وقعت الجملة الفعلية في محل الصفة ل رحمة وليست في محل جواب الطلب ل ارحمنا
ACEI & NSAIDs # in
renal hypoperfusion state
Renal hypoperfusion state casues?
Hypovolemia Extensice dose of loop diretics Heart failure Liver cirrhosis Nephrotic syndrome
ACEI Efferet VC
NSAIDS Afferent VD
Renal Hypoperfusion
Marked decrease in IGP And GFR
Glmerultubular balance?
tubuloglomerulat balance
in low GFR there is great reabsoprtion of Na Ca and H2O from tubule decreaisng urine volume
passage of Nacl in high amount to the macula densa decreasing PG synthesis thus decreaing VD of afferents so less GFR
Hypercalcemia and dehydration
Casuing vomiting and polyureae and dehydfration decreasing GFR and so increasing Reabsorption of Ca maitain the hypercalacemic state
IV saline to resolve the dehydration decreasing ca reabosortion
Loop direutic preventing reabsotption of Ca from Loop of Henle
CLASSIFICATION OF DIURTEIC ACCORDING TO K?
LOSING? Loop thiazide CAEI OSMOTIC
SPARING?>
Spironolactone , eplrenone
Amiloride , Triametrene
related to its natruretic effect
❖ High ceiling: Loop
❖ Moderate: Thiazides
❖ Low: K+ spairing & CAIs
All diureitcs except ? have to reach to the lumen of nephron to act → any defect in the delivery of diuretics to
lumen → ↓ responsee
spironolactone
Mannitol (osmotic diuretic): enters through GF. So Mannitol is # in ???because it can’t access to nephron → remain in blood → ?????? (Dilutional hyponatremia, Acute HF,…)
acute renal failure
circulatory overload
Loop & Thiazides: enter lumen through ??? → compete with→??
contraindicated in?
organic acid secreory system
uric acid secretion
Hyperuricemia and Gout
Amiloride & triamterene: → can be used in Gout??? why
enter through organic base secretory system
Loop diuretics: Their access to the lumen in renal failure is decreased due to accumulation of acid waste products in
blood → ↓ diuretic effect (Refractoriness: ↓ effect due to chronic use). Treatment:
↑ the dose of loop diuretics قرص ك
Spironolactone: enters to cells of DCT from ??????? to compete with aldosterone on its receptors
peritubular capillaries
thiazides + loop diuretic
In case of : Hyperplasia in early part of DCT due to chronic use of loop diuretics
to avoid refractoriness
Spironolactone + K losing diuretics
To avoid hypokalemia
Loop, thiazides, CAEI acidic drug ?
secteted by acid secretory sytem > hyperurecmeia # Gout
Amiloride trimatrine ?
secreted by oraginc base secretory system > used in Gout
Thiazides Less effective in RF (↓ GFR & Moderate ceiling). ???????????can be used in renal failure
Metolazone
Loop Dose should be increased in case of
Renal Failure
Mannitol # in Acute renal failure: can not reach to the lumen →
circulatory overload → # in acute renal faliure
. Hypokalemia ليه؟
+: قبل الخط Diuretics❖
decreaing Na reabsorption → ↑ Na+ delivry to the late part of DCT → ↑ Alodosterone → ↑ Na+ exchange with K+ and H+ → hypokalemia and alkalosis.
❖ Thiazides > loop: Part of delivered Na+ by loop diuretic is reabsorbed by early part of DCT before reaching macula densa
❖ Treatment: add
spironolactone
Diuretics inhibiting Na+
reabsorption → interfere with reabsorption of electrolytes related to Na+ at the site of action.
loop diureitcs ↓ Calcium (→Hypocalcemia) and Magnesium (→hypomagnesemia) reabsorption at ascending limb of
loop of Henle
هيبربوتاسيوم = هيبر ماجنسيوم والعكس صحيح reabsoprtion Magnesium ↑ spairing K
Loop dirutics work on ?
Thiazides?
Ascending loop of henle
Early part of DCT
lOOP examples?
frusemide : renal elmination with variable absorption
bumetanide hepatic elmination
toresmide
ThiaZides Examples/
Hydrocholrthalidone short acting
Chlotalidone long acting
Indapampide in HTN
Metolazone in Renal failure
Mechanism of loop
decerasing reabsorption of Na / k / 2cl and this leads to loss of Na20 and water
loss of meullary hypertonicity and loss absoprtion of water by medulla
loss of H20 > Na
PG production oVD of afferent and increasing GFR
decreasing the reabsorption of Na from the asecnding loop
#NSAIDS
Thiazaid mechnisms of action ?
Decreasing Reabsoption of Na at the early part of DCT and this exretion of Na and H20 > intial hypovolemia> movment of Na from the walls of blood vessels to blood
casuing VD
wHY LOOPS ARE USED IN ACUTE PULMONARY EDEMA/
DUE TO VENODILATOR EFFECT
whY USED LOOP IN ACUTE RENAL FAILURE ?
INCRSAING RENAL BLOOD FLOW
Thiazid are used in HTN ?
due to vasodilator effect
HTN and diretics?
loop diretics in hypertienon enephalipoathy
Thiaziade in HTN due to ?
1-intial diretic hypovolemic effect
2-2ry VD effect due to escape of Na from the wall of blood vessels into the blood
Indications of Loop diretics/
EEE
Emergency?
1-Acute pulmnary edema due to venodilator effect
2-Hypertensive enchepphalophaty
Edema referactory to other diuretics? Heart failure renal insufficincy liver ciirhosis ARF due to increased RBF
Electrolytes DISTURBACNES:
Hypercalacemia : after saline increase gfr decrasing the ca reabsoptiom
Hyperkalemia : decreasing K reabsorption at the loop
the na reaching macula densa and aldosterone exhanging the K with NA causing K excretion
Hypervolemic dilutional hyponaterima : H20»Na
Distal renal tubular acidosis exchnge of H with Na excerting The H+
Hypercalacemia :
and loop
after saline increase gfr decrasing the ca reabsoptiom
Hyperkalemia and loop
Hyperkalemia and loop
decreasing K reabsorption at the loop
the na reaching macula densa and aldosterone exhanging the K with NA causing K excretion
Hypervolemic dilutional hyponaterima :
H20»Na
Distal renal tubular acidosis
exchnge of H with Na excerting The H+
Distal renal tubular acidosis
exchnge of H with Na excerting The H+
Hert failrure and dirtucs?
Loop in acute heart failure
Thiazid in loop refecatriness in congestive heart failure
Adverse effects of loops
Hypovolenmia L hyptension collapse also thizia Hypokalemia < thiazide Hypomagneisuma also thi Hypocalacemia Hyperurecemia also thi Organs: ototoxicity 8th cranial nerve Git upset intersitial nephritis Myalgia Hypersenesitvity reactions Refractoriness
Thiazaid indication
cvs and renal
CVS
Hyper tension due to intial dirtic + 2ry VD effect
Congetice heart failure in loop refreactoriness
Renal :
nephrogein diabitus inspidus by decrasing PGs decasring GFR decreasing urine output
Idipathic calcuiria and ca stones : decreasing the GFR increasing the ca reabosortion
Mention adverse effects of the Thiazides?
Hypokalemia and alkalosis
HypoMangsisumia
Hyponatreima due to decrease exchangre at early part of distal convoluted tubule
Hyperureicemia due to acid competition
Hypersensitvity
Glucose intolerance potassium out of beta cells decrasing insulin release
Hyperlipidemia
Hepatic encephaloiphathy: NH4TO NH3 CROSSING BBB
impOtenece
Mention SPECIAL adverse effects of the Thiazides?
Glucose intolerance potassium out of beta cells decrasing insulin release
Hepatic encephaloiphathy: NH4TO NH3 DUE TO ALKALOSIS CROSSING BBB
Contraindications of Thiazides?
In edema of liver cirrhosis to avoid hepatic encephalopathy
In edema of renal failure cuz it is ineffective in low GFR
ethacrynic acid)
GIT upset
bumetanide)
Myalgia (
Kinetic refratoriness of the Loops?
1- Decrease in intestinal absorption due to decompenstaed heart failure what solve?
IV injection
2-Decreasing plasma protein binding due to nephrophaty or liver cirrhosis?
Mixing the drug with albumin in vitro
3-decerases excretion of diuretic by the acid secretory system due to renal failure due to accumulation of acid metabolites :
increases the dose of Frusemide 5 folds
Dynamic refratrincess of loop diuretics?
1-Hypertrophy of early part of DCT increasing Na reabosrption > Thiazide
2-Hyperalodsterniusm increasing na exchange with K in distal DCT > Spironolactone aldosterone antagonist
1K sparing dirtics
2osmotic
3carobonic anydrase
site of action ?
1-DCT
2-PCT and descending limb of loop of henele and Collecting tubule
3-PCT
indirect K sparings?
Spironloactone and Eplernone
Inhibits aldosternoe preventions of mediator protein synthesis
no synthesis of Na channels of luminal DCT
Used in CHF + LOOP + ACEI
Used in Hyperaldosteronism Edema
Delayed onset (3days)
Long acting
Direct K sparing?
Amiloride
trimaterene
Short onset
Short acting
Hypokalemia
HypoMagnusmia
Combined with K losing diuretics
Adverse effects of Potassium sparing diuretics ?
Hyperkalemia
Metabolica acidosis
INDirect spironlocatone Gyncomastia : due to anatgonizing androgen receptors
IVI Mannitol Mechanism of Action
?
filtration not rabsorped
increasing osmolarity of the urine keepin h20 in tubules
Pereserve Na and kick out h20
Mannitol not deffective in Heart failure?
due to Na over load edema
and mannitol is preserving agent of Na
decreasing reapsotoptrion of Na < < decreasing reabsorption of H2o
meaining it presreves Na and get rid of H2o
Osmotic diretics indications
IVI Mannitol is used in
Dehydrating agent for ?
Cerebral edema and icp
Acute glucoma IOP
Prophylaxis in ?- ARF pateint with oliguria caused by trauma or hemolytic reaction
Adverse effects of mannitol
only if in ARF? Cirulatory overload Acute heart failure Dilutional hyponatremia Acute pulmonary edema
Carbonic anhydrase inhibitors (CAIs)
Weak diuretic (most of Na+ lost is reabsorbed again in distal nephron)
Examples of CAEI
?
Acetazolamide
Methozolamid
Brizolamide
Dorzolamide
Mech of CAEI?
Easy!?
Decresing CAE Activity of production of H+ - Decreasing NaHCO3 reabsorption and it is excreted in urine
Alkaline urine
Acidic Blood
Methazolamide is preferred
Glaucoma: act & chronic. ↓
aqueous humor formation
Carbonic anydrase inhibitors indications ?
3E A
Emphysema and high altitude sickness
Excretion of acidic drugs as aspirin and barbituates toxicity
Epilipsy
Acute and chronic gluocoma methozolamide
Adverse effects of the CAEI ?
MRCH Metabolic acidosis and CNS depression Refractoriness Ca Po4 Stones (alkaline urine) Hypersensitvity
Amilordie ant triametrene pereferd than Spironloactone in hyokalmeia/
due to ability of daily adjustment of doseage dut to short action and rapid action
K-sparing diuretics are combined with K+ losing diuretics (thiazides& loop)
To potentiate their diuretic effect & to antagonize their hypokalemic effect (more effective than exogenous K+ & Mg
++ supplement)
Spirnolactone preferd in liver cirrhosise ?
In liver cirrhosis there is hyperaldosternoism and Spirnolactone and aldostenoe antagonist
Thiazide has minmal effect beacus lost na is reabsorped at the late part of DCT
Spironloactone not casuing Hypokalemia or alkalosis avoding hepatic encephalophathy
Loop diuretics can be used in refractory edema of liver cirrhosis only after ?
full dose of spironolactone why??? to avoid development
of hypokalemia and alkalosis that may lead to hepatic encephalopathy
Carbonic Anhydrase Inhibitors are weak diuretics:
because most of the fluids & Na+
lost are reabsorbed again at more distal sites
Loop & thiazides diuretics induce hypokalemia:
They ↑ Na+ delivered to late part of DCT → excretion of K+ & H+
in exchange with Na+ reabsorption by aldosterone (avoided by adding spironolactone)
Vasopressin receptors
• V1A: Vascular → ?
• V2: ?
• V1A & V1B :?
Vasoconstriction → control blood pressure
Renal → H20 reabsorption from collecting ducts
CNS receptors
(Vaptans) :Vasopressin Receptors Antagonists indications
Evlumic hyponateremia L SIADH High aldosterone
Hypervolemic Hyponatremia : Congestive heart failure
ACEI & NSAIDS are contraindicated in any cause of ??? to avoid development of acute renal
failure
renal
hypoperfusion
Lithium (antidepressant) toxicity is enhanced with
diuretics (Thiazides & loop)
NSAIDs inhibit Prostaglandin (PG) synthesis
VC Of aFFRENTS decrasing GFR
SIADH:
Syndrome of Inappropriate anti-diuretic hormone secretion
Hypercalcemia
Hypercalcuria
loop
thiazide
Hypokalemia
amiolride
triametrene
Hyperkalemia
Loop
Hypervolemic Dilutional Hyponatremia
Loop
Renal tubular Acidosis
Loop
Alkalosis due to sick sinus syndrome and
emphysema
CAEI
الحمدلله الذي أنزل علي عبده الكتاب ولم يجعل له عوجا
