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Pathophysiology Final > Chronic kidney disease > Flashcards

Chronic kidney disease Flashcards

1
Q

how many kidneys do we have?

A

2

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2
Q

where are the kidneys located?

A

upper abdominal area against the back muscles on both the left and right side of the body

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3
Q

nephron

A
  • basic functional unit of the kidney

- there are approximately 1 million nephrons/kidney

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4
Q

what is the main function of the nephron?

A

Its chief function is to regulate the concentration of water and soluble substances like sodium salts by filtering the blood, reabsorbing what is needed and excreting the rest as urine

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5
Q

what are the 2 main “parts” of the kidney?

A

1) blood supply

2) tubule part

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6
Q

what makes up a nephron?

A
  1. Glomerulus, *
  2. Efferent arteriole, *
  3. Bowman’s capsule, *
  4. Proximal convoluted tubule, *
  5. Cortical collecting duct, *
  6. Distal convoluted tubule, *
  7. Loop of Henle, *
  8. Papillary duct,
  9. Peritubular capillaries, *
  10. Arcuate vein,
  11. Arcuate artery,
  12. Afferent arteriole,
  13. Juxtaglomerular apparatus,
  14. interlobular artery (comes from the renal artery)
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7
Q

blood supply to the nephron

A
  • the afferent arteriole goes into the glomerulus
  • the efferent arteriole leaves the glomerulus (blood is carried out though here INSTEAD of a venule like with most capillaries)
  • The afferent artery is a branch of an interlobular artery in the cortex of the kidney
  • Contraction or relaxation of the artery can affect the pressure of capillaries in the glomerulus, and consequently the filtration of blood
  • peritubular capillaries are tiny blood vessels that travel alongside nephrons allowing reabsorption and secretion between blood and the inner lumen of the nephron
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8
Q

glomerulus

A
  • cluster of tiny capillaries that receives blood from afferent arteriole
  • blood passes through these capillaries and is filtered under pressure into the Bowman’s capsule
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9
Q

Glomerular filtration rate (GFR)

A
  • volume of blood filtered by the glomerulus each minute
  • normal adult GFR is around 100-125ml/min although this can vary on age and gender (it does decline with age)
  • used for staging chronic kidney disease and for drug dosing
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10
Q

GFR equation 1

A

CrCl by Crockcroft Gault formula

CrCL (ml/min/72kg) =((140-age)(88.4) x (0.85 if female)) / serum creatine (sCr)

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11
Q

creatine

A
  • byproduct of muscle metabolism that is freely filtered at the glomerulus and so can be used as a marker of GFR
  • serum creatinine levels remain fairly constant in healthy kidneys, but become elevated when renal filtration is impaired (therefore used as an indicator for kidney failure)
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12
Q

where is the first bit of urine produced in the glomerulus

A
  • in the bowman’s capsule

- this occurs under pressure

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13
Q

afferent arteriole

A

-arteriole through which blood enters the glomerulus

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14
Q

efferent arteriole

A

-arteriole through which blood leaves the glomerulus

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15
Q

what determines the tone and pressure of these arterioles and what does this control

A
  • relative VC/VD

- this controls the flow of blood

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16
Q

What combo of VC/VD do we NOT want?

A

-afferent constriction and efferent dilation

this can lead to kidney failure

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17
Q

what combo of VC/VD do we want, especially during low blood volume?

A
  • we want as much blood flowing through as possible
  • therefore we want to dilate at the beginning and constrict at the end
  • this keeps the pressure up to keep the blood flowing and filtering
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18
Q

tubular functions: secretion

A

is movement INTO the tubule, so that the substance may be eliminated

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19
Q

tubular functions: reabsorption

A

is movement out of the tubule into the capillary where it may be retained in the body -> back into the blood

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20
Q

flow of fluid/urine from the glomerulus

A
  • fluid filtered form the glomerulus flows into Bowman’s capsule and then into the proximal tubule
  • it then goes into the loop of henle, followed by the distal convoluted tubule
  • it finally goes to the collecting duct (it then goes into the minor calyx)
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21
Q

proximale convoluted tubule

A
  • 80% of the glomerular ultrafiltrate is reabsorbed back into the bloodstream as it passes through the proximal tubule
  • the urine produced is initially very dilute and lots of this is reabsorbed
  • reabsorption: nutrients (glucose, aas), electrolytes (Na, K, Cl, HCO3, Ca, PO4)
  • secretion: creatinine, uric acid, certain drugs
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22
Q

loop of henle

A

-fluid flows from the proximal tubule into the loop
-primary role is reabsorption of: water, Na, Cl, and Mg
(loop diuretics (furosemide) block reabsorption of Na and water is ascending loop)

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23
Q

distal convoluted tubule

A

reabsorption: Na and water
secretion: K, H, P
(thiazide diuretics work here)

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24
Q

collecting duct

A

reabsorption: Na
secretion: K (which is dependent on the hormone aldosterone)
- ADH (aka vasopressin) affects H2O permeability in the collecting duct (an increase in ADH results in concentrated urine, while a decrease leads to dilute)
- acid-base balance (excretion of acids)

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25
Q

diabetes insipidus

A
  • rare disease that results from a deficiency/ lack of endogenous ADH
  • kidneys produce an abnormally large volume of dilute urine
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26
Q

urea

A
  • normal values: 2.5-8mmol/L
  • blood test that measures the concentration of urea in the plasma, as waste product of protein metabolism
  • it is only a general indicator of renal function since it is reabsorbed in the kidneys and can be affected by other disease processes
  • it is a much less sensitive marker of kidney function than serum creatinine
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27
Q

what urea to creatinine ratio may indicate dehydration?

A

> 70

-urea will increase before serum creatinine in patients with acute kidney injury

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28
Q

electrolyte control: what happens to electrolytes in patients with chronic kidney disease

A
  • Sodium/water- edema/swelling (not able to decrease reabsorption by tubules)
  • potassium- increase in blood= hyperkalemia (not able to increase excretion from distal tubule)
  • phosphorus- increase in blood= hyperphosphatemia (not able to decrease reabsorption in proximal tubule and increase excretion from distal tubule)
  • magnesium- increase in blood= hypermagnesemia (not able to decrease reabsorption in loop of henle)
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29
Q

acid-base balance

A

-kidneys maintain the pH of arterial blood within a narrow range between pH 7.35-7.45 through acid-base regulation

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30
Q

acidosis

A
  • pH below 7.35
  • to fix: kidneys reabsorb all the filtered bicarbonate into the EF, and produce additional new bicarbonate
  • this helps to reduce the H ion concentration back toward normal
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31
Q

alkalosis

A
  • pH above 7.45
  • to fix: kidneys cannot reabsorb bicarbonate so it is excreted instead
  • the renal excretion of bicarbonate helps to increase hydrogen ion concentration back toward normal
32
Q

blood pressure control

A
  • through RAS (RAAS)

- renin is released by the stimulation of the juxtaglomerular cells

33
Q

juxtaglomerular

A
  • smooth muscle cells located in the walls of the arterioles
  • they act as baroreceptors, responding to subtle changes in circulating blood volume and pressure
34
Q

RAAS

A
  • renin-angiotensin-aldosterone system
  • decreased bp* -> renin released by kidneys-> angiotensin 1-> ACE-> angiotensin 2-> aldosterone secreted, VC, thirst stimulated-> H2) and Na retained-> increased arterial pressure
35
Q

what hormone do the kidneys produce

A

-erythropoietin (EPO)

produce 90% of the EPO found in the body- liver produces rest

36
Q

erythropoietin

A
  • stimulates the production of RBCs in the bone marrow

- when O2 levels in the blood fall below normal, the kidneys detect this change and respond by secreting EPO

37
Q

what happens to EPO production in CKD?

A
  • production goes down and patients’ RBCs/Hb decrease

- this is called anemia

38
Q

types of renal failure

A

1) pseudo
2) pre-renal
3) intrinsic
4) post-renal

39
Q

Pseudo failure

A
  • increases sCr due to blocking of renal tubular secretion of creatinine
  • falsely elevated creatinine: inhibition of renal tubular secretion of sCr
40
Q

Pre-renal failure

A
  • decreases blood flow to kidney-> decrease in GFR
  • by far the most common cause of acute kidney failure (50-60%)
  • may be due to various medical conditions
41
Q

what are some of the medical conditions that can cause pre-renal failure

A

1) intravascular volume depletion
2) decline in effective blood volume (advanced liver disease, CHF, antihypertensives, sepsis)
3) decrease pressure in glomerulus (afferent arteriole VC or efferent arteriole VD)

42
Q

Intrinsic AKI

A
  • structural damage to kidney
  • can effect either glomerulus or the tubules
  • 3 different causes (ATN, AIN, Glomerulonephritis)
43
Q

explain acute tubular necrosis (ATN) as a cause of intrinsic AKI

A
  • ischemia in kidney producing cell damage to tubules
  • most common cause of intrinsic failure
  • there are some medications that can induce this
44
Q

explain how acute interstitial nephritis (AIN) can cause intrinsic AKI

A
  • inflammatory disorder of the renal interstitium (“allergic reaction”)
  • drug can cause this
45
Q

explain glomerulonephritis as ca cause of intrinsic AKI

A

-results from stimulation of the IS leading to inflammation of the glomerulus
causes:
-DNA, proteins, viruses, and bacteria stimulate immune activation
-eg SLE (lupus nephritis), post-strep glomerulonephritis, diabetic nephropathy

46
Q

post-renal AKI

A 
-obstruction of urine flow:
kidney stones
bladder tumor/obstruction
uretral stricture/tumor
crystal deposition in renal tubules
*SOME KIND OF BLOCKAGE*
-can also be caused by certain drugs
47
Q

what are the 2 kinds of kidney dialysis

A
  • hemodialysis

- peritoneal dialysis

48
Q

hemodialysis

A
  • uses a man-made, semipermeable membrane (dialyzer) to filter wastes and remove extra fluid from the blood.
  • hospital
49
Q

peritoneal dialysis

A
  • uses the lining of the abdominal cavity (peritoneal membrane) and a solution (dialysate) to remove wastes and extra fluid from the body
  • home
50
Q

Can drugs be removed through dialysis?

A

yes

51
Q

is it an issue that drugs can be removed by dialysis?

A

yes- it affects frug dosing

52
Q

what factors predict drug removal during dialysis?

A

1) molecular weight
2) protein binding
3) volume of distribution
4) clearance

53
Q

Explain how molecular weight (MW) can affect drug removal

A

-hemodialysis dialyzers can remove drugs with MW up to 20,000 Daltons

54
Q

Explain how protein binding (PB) can affect drug removal

A

-primary drug binding proteins are albumin (69,000Da) and alpha 1-glycoproteins (44,100Da)
-if a drug becomes bound to one of these they cannot be removed from the body
-drugs that are over 90% protein bound cannot be removed by dialysis, even if the drug is very small (PB>MW)
ie- Sequinavir (MW 671, PD 98%); Cefotaxime (MW 477, PB 13-38%)

55
Q

Explain how volume of distribution (Vd) can affect drug removal

A
  • Vd describes the distribution of drug throughout the body
  • small Vd- distributed primarily in the blood compartment (Vd= 0.2-0.3L/kg)
  • large Vd- distributed widely throughout tissues& fluids outside of the blood compartment
  • drugs with large Vd exhibit less disability as compared with small Vd (large Vd has a relatively small % of dug within the blood and not accessible to the dialyzer)
  • if it is larger, it would have to undergo dialysis for longer than 4 hours to remove)
    ie) Amiodarone (Vd= 60L/kg); Gentamicin (Vd= 0.25L/kg)
56
Q

Clearance (renal vs nonrenal)

A
  • dialysis replaces renal clearance
    ie) Amiodarone (renal excretion less than 1%; extensively metabolized in liver) and Gentamicin (renal excretion 70% w minimal metabolism)
  • out of these 2, Gentamicin is more likely to be removed -> can look in the dialysis of drugs handbook
57
Q

how to navigate the dialysis of drugs handbook

A

-always look at the high permeability column- these dialyzers have a higher pore size and are likely to remove some drugs better than a convenient dialyzer
U= unlikely to remove
ND= no data
L= likely

58
Q

Is creatinine clearance calculation needed in someone receiving dialysis?

A

no

-people receiving dialysis are all considered to have a CrCl

59
Q

Hemodialysis Access

A

different methods:

  • AV fistula
  • dialysis graft
  • dialysis catheter
60
Q

AV fistula

A
  • AV (arteriovenous) fistula, which creates a direct connection between an artery and a vein
  • this is often done in the lower arm, but could also be the upper
61
Q

why is the lower or upper arm preferred for access for dialysis?

A

-much less chance of infection, as a foreign body does not have to be inserted into the vein

62
Q

PRILL

A

-pulsing of the blood at the arteriole-venous connection

63
Q

Dialysis graft

A
  • not preferred as clotting can happen very quickly
  • this can happen to ppl with bad veins as they cannot connect their actual veins to the artery
  • infection risk high- a foreign body is put into the body
  • *indirect connection between the artery and vein**
64
Q

Dialysis catheter

A
  • catheter used for hemodialysis is a tunneled catheter because it is placed under the skin
  • goes into the right atrium of the heart
  • getting a high blood flow supply
  • some ppl prefer this b/c it allows them to leave the dialysis unit faster than with the fistula- don’t have to hold the site of entry and wait until the blood clots (heparin dosing makes this a really long wait)
65
Q

Different types of Renal Replacement Therapy

A
  • hemodialysis
  • peritoneal dialysis
  • kidney transplant
66
Q

explain the treatment course of hemodialysis

A
  • 3x/week in dialysis centre (alternate days: MWF, TTS)
  • 6x/week nocturnal (done at home, long, slow dialysis at night for 6-8 hours)
  • short hour daily (2 hrs, 5-6 days/week)-> used for ppl that gain a lot of fluid weight during the break between dialysis times (ppl have hard time sticking to the fluid restrictions imposed on them)
67
Q

explain the treatment course of peritoneal dialysis

A
  • continuous ambulatory peritoneal dialysis (CAPD); done manually, patient hangs bags with 4-5 exchanges/day, 1 long dwell at night)
  • automated peritoneal dialysis (APD); patient hooks up to machine at night and machine does exchange)
68
Q

where is peritoneal dialysis always done?

A
  • at home
  • often preferred for people with children, or for people working full time
  • the catheter is often connected to the person, with the connection done to the machine at night
69
Q

Diffusion:

A
  • solvent moves by concentration gradient
  • we can control the dialysate bath to either remove or put back electrolytes into the blood by diffusion (K, Ca, Mg, bicarbonate)
  • patients often become acidotic- bicarbonate is high in the dialysate, and will diffuse back into the blood to neutralize the acid
70
Q

Ultrafiltration:

A
  • solution moves by pressure gradient
  • controls volume of fluid removed from the patient
  • dialysate pressure changes to achieve the prescribed fluid loss
  • every patient is prescribed a “dry weight” which is what they should weight after dialysis
71
Q

Osmosis:

A
  • water moves by concentration gradient
  • in dialysis, this refers to water movement across cell membranes in the body (e.g. either from within the RBC to the blood plasma, or from within cells of the various tissues in the body (like muscles) to the interstitial fluid (fluid in between cells))
  • sodium profiling can be used to increase rate of osmosis early in the treatment by increasing the sodium level of the plasma by using a higher sodium level in the dialysate
72
Q

what are both osmosis and ultrafiltration used for?

A

-remove excess fluid from the body

73
Q

Why get a kidney transplant?

A
  • life expectancy increases by a large amount (biggest benefit is if age 20-39)
  • you can save up to $50000/year
74
Q

Where does the new kidney go?

A
  • it is not in the same place as the original kidney

- it is usually placed on the lower abdomen on the front side, and will be attached to the bladder from there

75
Q

Is it easy to get a transplant in MB?

A
  • wait time for a living donor is at least 1 year; for a deceased donor its at least 3 but varies based on your blood type
  • blood types have to be a match
  • they try to match people up with a kidney of their blood type using the “paired exchange program”
76
Q

pre-emptive transplant

A

-try to do the kidney transplant before someone ever has to start dialysis

77
Q

primary causes for kidney disease

A 
#1- diabetes b/c you can develop diabetic nephropathy
#2- HTN

Pathophysiology Final (10 decks)

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