Exam 2 Flashcards
1
Q
What is the role of the glomerulus?
A
The initial filtration of blood
2
Q
How many nephrons are there per kidney?
A
1-2 million
3
Q
What is the role of mesangial cells?
A
They contain growth factors, control matrix proteins, and contractile ability
4
Q
What is the role of the basement membrane?
A
Gives the membrane structure
5
Q
What causes protein and blood to be filtered into the blood?
A
disease or damage to the kidney
6
Q
What is Azotemia?
A
elevation of BUN and creatinine where there is a decrease in GFR
7
Q
What is uremia?
A
Excess of urea and other nitrogenous waste in the blood
8
Q
Is uremia a toxic condition?
A
Yes
9
Q
What causes Uremia?
A
Failure of renal excretory function, metabolic and endocrine alterations and renal damage
10
Q
What is proteinurea?
A
protein in the urine
11
Q
What is hematuria?
A
blood in the urine
12
Q
what is natureisis?
A
excretion of sodium
13
Q
Water follows ____?
A
Sodium
14
Q
What characterizes acute kidney disease/injury/failure?
A
Abrupt decrease in GFR or increase in SCr
15
Q
How is AKD classified?
A
RIFLE
- Risk
- Injury
- Failure
- loss of function
- End stage kidney disease
16
Q
What are the 3 types of AKD?
A
Prerenal
Intrinsic
Postrenal
17
Q
What is prerenal AKD?
A
decreased renal blood flow
18
Q
What is intrinsic AKD?
A
A structure within the kidney is damaged
19
Q
What is postrenal AKD?
A
An obstruction is present within the urine collection system
20
Q
What is CKD?
A
Progressive loss of function over several months to years
and is characterized by the gradual replacement of normal kidney tissue with parenchymal fibrosis
21
Q
What are 3 chronic disease states that influence CKD?
A
DM, HTN,HLD
22
Q
What is hemodialysis?
A
Perfusion of blood and dialysate on opposite sides of a semipermeable membrane.
23
Q
What force removes substances from the blood in hemodialysis?
A
diffusion and convection
24
Q
How is excess plasma water removed in hemodialysis?
A
Through ultrafiltration
25
What is peritoneal dialysis?
Instillation of dialysate into the peritoneal cavity via a permanent peritoneal catherer
26
What are some causes of drug induces kidney disease?
Antibiotics
Diuretics
NSAIDS
Can all cause analgesic nephropathy and kidney necrosis
27
What is nephritis?
Chronic glomerulonephritis is the most common chronic renal failure in humans
28
What are the 2 types of chronic glomerulonephritis?
primary
| secondary- associated with systemic diseases (SLE, HTN, DM)
29
What are 3 immune reactions that are involved in glomerular disease?
1. Antibody associated disease
2. Cell - mediated
3. Other mechanisms
30
What are 2 types of antibody mediated glomerular injury?
Circulating antigen-antibody complexes
| Anti Glomerular Basement Membrane Antibodies
31
How do ciculating antibodu complexes work?
The complexes deposit in the basement membrane-->body attacks membrane--> membrane breaks down--> proteinurea
32
What are 3 major glomerular syndromes?
1. Nephrotic syndrome
2. Nephritic syndrome
3. Chronic glomerulonephritis
33
What causes Nephrotic Syndrome?
The blood vessels in the glomeruli become leaky which allows proteins to leave the body
34
What causes Nephritic syndrome?
associates with disorders affecting the kidneys, glomerular disorders
35
Nephrotic syndrome symptoms
```
proteinuria
hypoalbuminemia
edema
hyperlipidemia
lipiduria
```
36
Nephritic syndrome symptoms
hematuria
oliguria
azotemia
hypertension
37
What is acute pyelonephritis?
a bacterial spread, usuually ascending from a bladder infelction, vesicoureteral reflux and interenal reflux
38
What is a simple cyst?
A bag-like sac filled with fluid or air
| Benign- not a tumor
39
What does APKD stand for?
Autosomal Dominant Polycystic Kidney Disease
40
What is APKD?
multiple expanding cysts of both kidneys that destroy tissue
41
What gene causes APKD?
PKD1 or PKD2
42
what is the Tx for APKD?
Kidney transplant
43
What gene causes autosomal recessive polycystic kidney diease?
autosomal recessive inheritance
| mutation in PKHD1
44
What are the effects of ARPKD?
Infants often die of pulmonary or renal failure
fibrocystin (polyductin)
congenital hepatic fibrosis
45
What is diuresis?
increase in urine volume
46
What is naturesis?
increase in renal sodium excretion
47
What are the clinical uses of diuretics?
HTN, edema, CHF, CKD, hepatic cirrhosis, hypercalcemia, Diabetes insupidus
48
Where do acetazolamides act?
The proximal convoluted tubule
49
Where do osmotic agents (mannitol) act?
The PCT
50
Where do loop diuretics act?
the thick ascending limb of the loop of henle
51
Where do thiazide diuretics act?
The proximal straight tubule and DCT
52
Where do aldosterone antagonists act?
in the collecting tubule
53
Where do ADH antagonists act?
In the collecting duct
54
Where does adenosine act?
The glomerulus, the PCT and the thick ascending limb
55
What are three examples of look diuretics?
Furosemide
Bumetanide
Ethacrynic Acid
56
What are 2 examples of thiazides?
HTCZ
| Chlorthalidone
57
What are some K+ sparing diuretics?
Spironolactone
Triamterene
Amiloride
58
How doe K+ diuretics work?
They block the reabsorption of Na+ in the collecting tubule so K+ is not lost
59
What are 7 ways ions/solutes can move across membranes?
```
Convective
Simple diffusion
channel mediated diffusion
facillitated diffusion
ATP- mediated
Symport
Antiport
```
60
What are the 7 kinds of diuretics?
1. Carbonic Anhydrase Inhibitors
2. Loops Diuretics
3. Thiazides
4. Collecting Tubule Diuretics
5. Aldosterone Antagonists
6. Osmotic Diuretics
7. ADH Antagonists
61
Which diuretic is the least effective?
Carbonic Anhydrase Inhibitors
62
Why are carbonic anhydrase inhibitors not very effective
Because there is so much other absorption of Na+ and H2O in the rest of the nephron
63
What class does Acetazolamide belong to?
CA inhibitors
64
What is the brand name of acetazolamide?
Diamox
65
What ions maximize the diuretic activity of diuretic?
Cl-, Br- CF3-, or NO2
66
What effect does the substitution of an amine have on the CA inhibitors?
It increases the naturetic activity
| Decreases the the CA inbhibitor activity
67
What functional group is required for diuretic activity?
```
unsubstituted Sulfamoyl (allergenic)
H2NO2S
```
68
By what actions does diamox work as a diuretic?
Decreases NaHCO3 reabsorption
| Deacreases H2O reabsorption
69
What are 4 clinical uses for diamox besides a diuretic?
Acute Mountain Sickness
Metabolic Alkalosis
Glaucoma
Uriniary Alkanization
70
What are 3 side effects of acetazolamide?
1. Drowsiness/paresthesia
2. renal stones
3. low potassium
71
What is a toxcicity of acetazolamide?
1. hyperchloremic metabolic acidosis
72
What are 2 contraindications for acetazolamide?
Hepatic Cirrhosis
| Sulfa allergies
73
What are 4 loop diuretics?
1. Furosemide
2. Bumetanide
3. Ethacrynic Acid
4. Torsemide
74
What ions do loop diuretics affect?
Na+, 2Cl-, K+, Mg2+, Ca2+
75
What is the name of the transport system loop diuretics inhibit?
Na+/2Cl-/K+ symport
76
What is the brand name of furosemide?
Lasix
77
What is the brand name of torsemide?
Demadex
78
Which of the loop diuretics is a prodrug?
Ethacrynic acid
79
What is the brand name of ethacrynic acid?
Edecrin
80
Is edecrin an electrophile or nucleophile?
Electrophile
81
How do loop diuretics work?
- inhibit Na+/2Cl-/K+ reabsorption (also Mg+2 and Ca+2)
| - increase renal blood flow through vasodialation induced by prostaglandins (this increases GFR)
82
What are some advantageous characteristics of loop diuretics?
- rapid IV response
| - Duration of action dependent on renal function
83
What are some side effects of loop diuretics?
```
dehydration
dose dependent reversible ototoxicity
hypomagnesemia
hyperuricemia
Hypokalemic metabolic alkalosis
```
84
What patient population does hypouricemia effect?
Gout patients (losing H2O concentrates uric acid- deposits in joints and causes autoimmune rxn)
85
what are some clinical uses for loop diuretics?
```
edematous conditions
acute pulmonary failure
acute hypercalcemia
hyperkalemia
acute renal failure
anion overdose
```
86
What part of the nephron do thiazides act on?
The DCT
87
What transport system do thiazides inhibit?
Na+/Cl- symport
88
What are the 2 kinds of DCT diuretics?
1. thiazides
| 2. thiazide like diuretics
89
What are 3 thiazide like diuretics?
1. chlorthalidone
2. indapamide
3. metolazone
90
What is the brand name for chlorthalidone?
Hygroton
91
What is the brand name for indapamide?
Lozol
92
What is the brand name for metolazone?
Diulo
| Zaroxolyn
93
What are the 2 actions of thiazide diuretics?
1. inhibit the Na+/Cl- symport
| 2. Enhance Ca+2 reabsorption
94
What are the clinical applications of thiazides?
HTN
CHF
Nephrolithiasis from idiopathic hypercalciuria
Nephrogenic Diabetes insipidus
95
What are some side effects of thiazides?
```
hypokalemic metabolic acidosis
hyperuricemia
impaired carbohydrate tolerance
hyperlipidemia
hyponatremia
```
96
What is a contraindication of both loop diuretics and thiazides?
Sulfa allergies
97
How does thiazide diuretics treat diabetes insipidus?
DI- is high UOP
| Thiazides use a paradoxical effect to cause less pressure naturesis in the glomerulus which decreases GFR so less UOP
98
What are diuretics that act on the CT?
amiloride
triamterene
spironlactone
eplerenone
99
What is the brand name of amiloride?
Midamor
100
What is the brand name of triamterene?
Dyrenium
101
What transport system does CT diuretics inhibit?
Na+ channel
102
How does blocking the Na+ channel of the CT affect K+ excretion?
it reduces K+ excretion- K+ sparing
103
What is the brand name of spironlactone?
Aldactone
104
What is the brand name of eplerenone?
Inspra
105
By what mechanism do aldactone and inspra work?
Aldosterone antagonistsw
106
What is the clinical use of amiloride and triamterene?
- Conjunctive therapy with a thiazide or loop diuretic for CHF or HTN
- edema from CHF, hepatic cirrhosis, hyperaldosteronism or nephrotic syndrome
107
What are some contraindications of amiloride and triamterene?
K+ supplements
ACE inhibitors
Pts prone to kidney stones- triamterene
108
What are 3 side effects of triamterene and amiloride?
hyperkalemia
| hyperchloremic metabolic acidosis
109
What does AIP stand for?
Aldosterone Induced Proteins
110
What effect does aldosterone have on Na+ and H2O
It increases Na+ nad H2O retention by acting as a steroid hormone on the nucleus to promote transcription of AIPs
111
What are the 2 actions of spironlactone?
aldosterone inhibitor
| inhibits 5alpha reductases
112
What is the job of 5alpha reductases?
to create active metabolites of aldosterone
113
What are the clinical uses of spironlctone?
Mineralcorticoid excess
primary or secondary hyperaldosteronism
HTN or CHF tx w/o other diuretics
114
What are some side effects of spironlactone?
```
hyperkalemia
hyperchloremic metabolic acidosis
gynecomastia
impotence
BPH
```
115
For what conditions is spironlactone contraindicted?
K+ supplementartion
ACE inhibitors
CKD
116
What is the advantage of inspra over aldactone?
It is more selective for the mineralcorticoid receptor
117
What are some side effects of inspra?
Hyperkalemia
| HLD
118
What are the contraindications for inspra?
```
CYP3A4 inhibitors
ACE inhibitors
K+ supplementation or sparing diuretics
diabetes associates with microalbuminuria
CKD
```
119
What diuretic is the only one to not work by sodium loss?
Mannitol
120
How does mannitol work?
It creates osmotic resistance that limits water reabsorption in the PCT, DCT and Loop
121
What are the clinical applications for mannitol?
Increases urine volume
| Reduces intracranial or intraocular pressure
122
What are some side effects of mannitol?
Extracellular volume expansion
Dehydration
Hypernatremia
123
Which diuretic is an ADH Antagonist?
Demeclocycline
124
What is the brand name for Demeclocycline?
Declomycin
125
What is demeclocycline a derivative of?
tetracycline
126
What is demeclocycline indicated for?
SIADH
| High ADH
127
What are some side effects of demeclocycline?
nephrogenic diabetes insipidus
| renal failure
128
Define ESRD
A patient with < 15 GFR
| Needs dialysis or a kidney transplant
129
What are the 3 major causes of CKD?
1. DM
2. HTN
3. Glomerulonephritis
130
How does DM cause CKD?
Glucose is a large molecule that when at high concentrations will bend and tear the glomerular filter over time and tear up the kidney
131
How does HTN cause CKD?
High pressure in the bowmans capsule will tear up the filter over time as it pushes solutes through
132
What are the CKD classifications based on?
Cause, GFR and Albuminuria
133
What are 2 additional causes of CKD?
HIV nephropathy
| Polcystic kidney disease
134
At what GFR flow rate do we start to worry?
<60ml/min/1.73m^2
135
What flow rate is indicated at CKD stage G3a?
45-59 ml/min/1.73m^2
136
What flow rate is indicated at CKD stage G3b?
30-44 ml/min/1.73m^2
137
What flow rate is indicated at CKD stage G4?
15-29 ml/min/1.73m^2
138
What flow rate is indicated at CKD stage G5?
<15 ml/min/1.73m^2
139
What is normal GFR?
>90 ml/min/1.73m^2
140
How many categories does albumenuria have?
A1, A2, A3
141
What albumin excretion rate (AER) is present at A1?
< 30 mg/24 hours
142
What AER is present at A2?
30-300 mg/24 hours
143
What AER is present at A3?
>300 mg/24 hours
144
What kind of patients can the Crockroft Gault equation be used for?
Only accurate in patients with stable kidney function
| CKD considered stable, AKD is not stable
145
What is the Crockoft Gault equation?
Men: CrCl = [(140-age)IBW]/(Scr x 72)
Women: multiply CrCl by 0.85
146
Does the Crockoft Gault equation over or underestimate renal function in severe CKD?
Overestimates because of the 10% of secretion present right after the glomerulous
147
MDRD equation is used for what?
Categorizing CDK
148
what is the MDRD equation?
GFR = 170 x (Scr)^-0.999 x age^-0.178 x [0.762 if female] x [1.180 if black] x [Serum nitrogen concentration]^-0.170 x albumin^0.318
149
When _____ function of the kidney is compromised, metabolic acidosis occurs?
Maintenance of the acid balance in plasma (secreting H+ ions)
150
When _____ function of the kidney is compromised, anemias occur?
The secretion of hormones like erythropoietin, rennin and PGAs
151
When ______ function of the kidney is compromised mineral and bone disorders occur?
Synthesis of calcitriol and secretion of phosphate
152
What are monitoring parameters for uremia?
BUN
| Scr
153
What levels of Scr and BUN make a candidate for dialysis?
BUN ~100
| Scr ~ 10
154
What effect does CKD and ESRD have on the CNS?
Encephalopathy
155
What effect does CKD and ESRD have on the EENT?
Uremic fetor ( urine smelling breath)
156
What effect does CDK and ESRD have on the pulmonary system?
Non cardiogenic pulmonary edema from volume overload
157
What effect does CKD and ESRD have on the Cardiovascular system?
LVHF, volume overload, sodium retention
158
What effect does CKD and ESRD have on the GI?
Anorexia, N/V, constipation, and metallic taste
159
What effect does CKD and ESRD have on the musculoskeletal system?
Mineral and bone disorders, restless leg syndrome
160
What effect does CKD and ESRD have on anermia?
EPO deficiency
161
What effect does CDK and ESRD have on the skin?
formation of uremic frost
162
Do you always fluid restrict a fluid overloaded patient?
No, not generally necessary IF Na+ levels are controlled
| avoid large amounts of free water
163
Will diuretics work in a stage 5 CKD patient?
NO, require functioning kidneys (direct correlation)
164
What is a solution for loop diuretic resistance?
Add a thiazide
165
Are thiazides effective at CrCl < 30ml/min?
No
166
Are loops effective at CrCl < 30 ml/min?
yes
167
Which loop diuretic can be used in sulfa allergy patients?
ethacryinic acid
168
What is the predialysis K+ goal for ESRD patients?
4.5-5 mEq/L
169
What are some high K+ food?
Tomatoes, dried fruits, salt substitutes, fresh fruits
170
Is sodium bicarb used in ESRD patients?
No
171
What term means dietary intake of Phos?
Phosphate
172
What term means the portion of phos in the blood?
Phosphorous
173
Hyperphosphatemia has a direct role on ______ and an indirect role on _______?
1. secondary parathyroidism
| 2. formation of kidney stones due to hypocalcemia
174
Low vitamin D due to reduced GFR can cause what?
High iPTH
175
What do hyperphosphtemia, hypocalcemia and low vit. D have in common?
High iPTH
176
What is a treatment for hyperphosphatemia?
Give a phosphate binder with ALL MEALS
177
What are 2 kinds of Calcium containing phosphate binders?
Calcium Carbonate --> Tums
| Calcium Acetate---> PhosLo
178
Calcium carbonate is ___% elemental Ca?
40%
179
Calcium acetate is ___% elemental Ca?
25%
180
What is the does of Tums?
500mg TID a meals
181
What is the maximum mount of elemental calcium?
1500mg/day
182
What is the does of calcium acetate?
667mg 2-3 tablets TID a meals
183
When given the same elemental dose, which calcium containing phosphate binder will bind double that of the other?
Calcium Acetate
184
Which Ca+ containing phos binder has fewer hypercalcemic events?
calcium acetate
185
What are 5 non Ca containing phos binders?
1. Sevelamer Carbonate (Renvela)
2. Lanthanum Carbonate (Fosrenol)
3. Sucroferric Oxyhydroxide (velphoro)
4. auryxia (ferric citrate)
5. Aluminum Hydroxide (Amphojel)
186
Which phosphate lowers [Uric acid], LDL and A1C?
Sevelamer carbonate
187
What are the ADE of Sevelamer carbonate?
GI- upset, nausea, vomiting, diarrhea
188
What is the sevelamer dose for phos 5.5 < 7.5 mg/dl
800 mgTID
189
What is the sevelamer does for phos >7.5 mg/dl ?
1600mg TID
190
What is the dose of lanthanum carbonate?
250-750 mg TID
191
What is the max dose of lanthanum carbonate?
1500-3000 mg/day
192
What is a side effect of sucroferric oxyhydroxide?
Darkened stools from the iron
193
What is the dose of sucroferric oxyhydroxide?
500 mg chewable tab TID
194
What are 2 drug interactions with ferric citrate?
Levothyroxine
| Paracalcitriol
195
What is the Auryxia dose?
2 tablets TID
196
Auryxia can cause dark stool true or false?
True
197
What are 2 labs Auryxia will elevate?
TSAT
| Ferritin
198
What is the aluminum hydroxide dose?
300-600 mg TID
199
Which Phosphate binder is used for short term use of < 4 weeks?
Aluminum Hydroxide
200
What are side effects of Aluminum Hydroxide?
constipation, Al toxicity cause patients can't secrete Al
201
What level should dietary phosphorous be limited too?
800-1000 mg/day
202
When should dietary phos be limited?
G5 if phos > 5.5 mg/dl
| G4/G3 if phose > 4.6 mg/dl
203
How does renal dysfunction cause hyperparathyroidism?
Hyperphosphatemia and the kidneys can't activate vitamin D causes low Ca. Low Ca triggers the parathyroid to secrete PTH
204
What is the role of PTH?
To Increase calcium mobilization from the bone
205
How do vitamin D supplements effect PTH ?
Increased Vit. D --> decreased PTH
206
Is cholecalciferol an inactive active form?
Inactive vit. D
207
Is Ergocalciferol an active or inactive form?
inactive Vit D
208
Which is the active form of Vit D?
Calcitriol
209
Is Ergocalciferol (Calciferol) active or inactive
inactive
210
Is cholecalciferol active or inactive?
inactive
211
is calcitriol active or inactive?
active
212
What is the generic and form of Rocaltrol?
calcitriol, PO
213
What is the generic and form or Calcijex?
calcitriol, IV
214
What is the indication for inactive vitamin D supplements?
CKD stage 3 and 4 patients with some renal function
215
Which vitamin D supplement is approved in Peds and has the greatest risk of hypercalcemia?
Calcitriol
216
What is the brand name of Paricalcitol?
Zemplar
217
Is paricalcitol active or inactive?
Active
218
Which vitamin D supplement has the most favorable ADE profile and less calcemic activity?
parocalcitol
219
Is Doxercalciferol active or inactive?
active
220
What is the brand name of doxercalciferol?
hectorol
221
Which vitamin D supplement is a prohormone?
doxercalciferol
222
Where is doxercalciferol activated?
The lover
223
Which vitamin D supplement has a higher incidence of hyperphosphatemia?
doxercalciferol
224
Which drug that lowers PTH is in the calcimimetic class?
Cinacalet (Senispar)
225
How does senispar work?
It irreversibly binds to the outside of calcium receptors on the PTG and changes the conformation so iPTH is decreased cause the gland thinks Ca is there .
226
What is the danger of senispar?
The parathyroid can't sense hypocalcemia any more
227
Wht kind of vitamin D does a patient need if the have high Vit. D concentration and high iPTH?
Active
228
What kind of vitamin D does a patient need if the have high iPTH and low to normal Vit D?
inactive
229
What is the main cause of anemia in CKD patients?
Decreased erythropoietin production
230
What effect does uremia have on anemia?
It decreases the lifespan of RBCs
231
What kind of hemolysis is specifc to CKD patients?
hemolysis through the dialyzer
232
What is MCV?
average volume of the RBC
233
What kind of anemia is characterized by low MCV?
microcidic anemia
234
What anemia is characterized by high MCV?
macrocidic anemia
235
What is normal red cell distribution width? (RDW)
11.5-14.5%
236
What kind of anemia does folate and B12 deficiencies cause?
Macrocidic anemia
237
What kind of anemia does iron deficiency and aluminum toxicity cause?
Microcidic anemia
238
What causes of anemia don't effect MCV?
GI bleeding
EPO deficiency
Anemia of chronic disease
239
What is the Hb goals in females? in males?
<13 g/dL
240
According to KDIGO what are the labs that suggest iron supplementation?
< 30% TSAT
| Serum Ferritin < 500 ng/mL
241
How often should TSAT and ferritin monitored?
q 3 months
242
How often should Hb be monitored in CKD 3 patients?
annually
243
How often should Hb be monitored in CKD 4-5ND patients?
bianually
244
How often should Hb be monitored in CKD 5D patients?
q 3 months
245
Can you give oral iron to CKD 5 patients?
No
246
What is the dose of elemental iron needed for CKD patients?
200 mg/day
247
What is the requirements for heme iron?
24-36 mg/day
| different absorption/sites
248
What is unique about Dexferrum?
It is a high MW Fe--> causes more anaphalaxis
249
Which IV iron agent needs a test dose?
Iron dextran (infed) cause the dextran can cause anaphalaxis
250
what is unique about Feraheme?
It can cause MRI imaging problems for up to 3 months
251
Which IV iron can be given to ND-CKD pts?
iron sucrose
252
What is a precaution with ferrlicit?
If it is infused to quickly we can cause Oxidative stress
253
What are some dangers of oxidative stress?
athlerosclerosis, proteinurea, renal tubular damage
254
For CKD 3-5ND when is it indicated to begin ESA?
Hb < 10 g/dL and falling rapidly
255
For CKD 5 patients when is ESA indicated?
When Hb is 9-10 g/dL
256
What is the Hb increase limit for ESA?
11.5 g/dL
257
What is rHuEPO?
recombinant human erythropoietin
258
How does rHuEPO work?
It stimulates erythroid progenitor cells
259
What are the EDE of ESA?
Pure red cell aplasia- Ab develop to EPO
260
When is dialysis started to fix bicarb?
HCo3- < 20 Mer/L
261
What is the recommended protein for GFR< 30mL/min?
0.8 g/kg/day for CKF 3-4
262
What is the protein needed for ESRD patients?
1.2 g/kg/day
