FEN/Renal Flashcards
Pasteurization destroys immunological properties of milk - what is destroyed and what is preserved?
IgM destroyed; IgA and IgG are preserved
Deficiency: diaper dermatitis, hypoalbuminemia, crusted rash perioral
Zinc - important component of enzymes like carbonic anhydrase, important for growth; inherited form is acrodermatitis enteropathica (AR); defective zinc uptake in duodenum/jejunum bc abnormality in Zinc transporter protein ZIP4
What do selenium and chromium do?
Selenium: cofactor for glutamine peroxidase, antioxidant (deficiency = cardiomyopathy)
Chromium: regulates glucose levels, role in insulin metabolism (unknown side effect of deficiency)
Copper’s role and deficiency
critical for RBC and Hgb formation, absorption of iron
Deficiency: anemia, osteoporosis, pigmentation of hair and skin, neutropenia, poor weight gain, hypotonia/ataxia
Describe the 3 types of RTA, urine pH, serum K, hyperCalciuria
1 (distal): diminished acid secretion,»_space;6.5 urine pH, low-normal K, YES hyper Ca in urine
2 (proximal): failure to absorb bicarbonate; <6.5 urine pH, low-normal K, NO hyper Ca in urine
4 (aldosterone deficiency/resistance); pH < 6.5 in urine, high K, NO hypercalciuria
When do lactase and intestinal disaccharidases ready adult c concentrations?
Lactase: 36 weeks
Disaccharides: 28 weeks
Whey to casein ratios for colostrum, mature BM, preterm formulas
Colostrum: 80:20
Mature BM: 55:45
Preterm formulas: 60:40
Over time in ELBW, what happens to TBW, ECF, ICF?
TBW, ECF, and NaCl are DECREASING (TE-creasing)
at 3 mo, ICF = ECF
At 24 weeks, ECF 65, ICF 25
Deficiency: alopecia, scaling dermatitis, seborrhea
Biotin deficiency
Ascorbic acid deficiency:
wound healing poor, bleeding gums, associated with transient tyrosinemia
Retinol function and deficiency
pulmonary epithelial growth and cellular differentiation, may be associated with CLD; deficiency = photophobia, conjunctivitis, abnormal epiphyseal bone formation and tooth enamel, scaling, FTT
Riboflavin vs Thiamine
Riboflavin: FTT, photophobia, blurred vision, dermatitis, mucositis, glutamic aciduria type 1
Thiamine: beriberi; fatigue, irritability, constipation, cardiac failure; PDH complex deficiency and MSUD
When does first glomeruli develop and when is nephrogenesis complete? How many nephrons at that time
Pronephros: 2-3 weeks
First glomeruli at 9 weeks
Nephrogenesis completes at 34-36 weeks (1 million nephrons)
Urine production nat 10-12 weeks
90% of amniotic fluid is urine at 20 weeksI
In infants, kidneys only receive _____% of CO
10%
Copper is stored primarily in _____. and Begins to accumulate in _____ trimester
Liver; 3third trimester
Menkes disease
X-linked recessive; inability of cellular absorption of copper. Difficult to dx bc lack of normal values, large variation in copper/ceruloplasmin values
Hypochromic anemia, NEUTROPENIA, osteoporosis
What is the one thing cow’s milk has more than BM?
amino acids. Otherwise BM has more long chain PUFA, carnitine, cholesterol, docosahexaenoic acid
Preterm vs term milk?
Preterm milk has more protein, NaCl, PUFA, but LOWER lactose
Most variable component of human milk is ______
Triglycerides! depends on GA and maternal diet. Cholesterol is constant and independent of maternal diet
Protein should provide ____% of kcal to prevent catabolic state
7-15%
Selenium vs chromium vs zinc functions
selenium: glutathione peroxidase, antioxidant
Chromium: carb/lipid metabolism (deficiency not described)
Zinc: bone development
Preterm vs term formula differences
Preterm formula has higher protein, sodium, but lower lactose compared to term formula
Preterm formula is ISO-osmolar unless > 24 kcal
Absorptive functions of jejunum and ileum
Jejunum: protein, fat, carbs, iron, CA, Mg
Ileum: B12, releases neurologically important hormones, absorbs bile salts, fats, FAT-SOLUBLE VITAMINS, zinc
Foremilk vs hindmilk
Foremilk has higher lactose but lower fat. Same protein.
What is Lowe syndrome
X-linked recessive, Golgi apparatus. Oculocerebrorenal syndrome
Why do preterm infants have higher serum Cr in first few weeks of life compared to term?
Preterm has greater reabsorption of filtered Cr in leaky renal tubules and lower Cr clearance bc impaired glomeruli filtration
Describe renal embryology
Pronephros: 2-3 weeks, regress by 4 weeks
Mesonephros –> mesonephric tubule and duct
Mesonephric duct –> ureteric bud –> collecting ducts –> nephrons
Renal genesis occurs when ureteric bud FAILS to develop
If ureteric bud forms but no interaction with undifferentiated mesoderm –> renal dysplasia
When is vesicoamniotic shunt indicated?
2nd trimester (20 weeks)
Most common cause of hydronephrosis?
no specific anomaly
Prerenal vs renal tubular injury (urine osm, urine Na, FeNa)
Prerenal: urine ism high, urine Na low, FeNa < 2%
Renal tubular injury: urine ism low, urine Na high, FeNa > 2%
What is the role of placental lactogen?
Growth and development of fetus by coordinating metabolic and nutrient supply from pregnant woman to the developing fetus
Preterm infants can reach urine osm of _____ while adults can reach _____
500, 1200
Radiant warmer increases insensible water losses by _____ %. Steroids _____ IWL.
15-35%, DECREASE
Risk factors for renal vein thrombosis?
Prematurity, PV, maternal diabetes
IgA represents ____% of all IG in human milk. IgM _____ over time in lactating mothers.
90%; decreases
What is potter syndrome?
Oligohydramnios –> pulmonary hypoplasia –> physical deformities of face and extremities (renal agenesis, hypoplasia or bladder outlet obstruction)
What are extra-renal complications of autosomal recessive polycystic kidney disease?
Pulmonary hypoplasia, systemic hypertension, 45% liver involvement
Bile salts are _____ molecules while lipases are ____-soluble
amphiphilic; lipases are water soluble
Free fatty acids, bile salt, and monoglycerides form a ____
micelle –> contact with intestinal wall –> FFA and monoglyceride diffuse across plasma membrane into enterocyte. Within enterocyte, free fatty acids and monoglycerides are transported to ER and then re-esterified into TG and incorporated into chylomicrons –> packaged into exocytic vesicles in Gogli apparatus
Plasma osmolality equation
2 x Na + glucose / 18 + BUN / 3
Sx of essential fatty acid deficiency
dermatitis, THROMBOCYTOPENIA, increased infection, failure to thrive
Resting energy expenditure of a VLBW or ELBW infant is_____, while fecal loss of energy is ______
50 kcal/kg/day
10 kcal/kg/day
Growth in preterm infant =
REE x 2 + energy losses
For each gram of protein supplied enterally, there is a ____ increase in weight and a _____ cm/week increase in HC
6.5 g/day; 0.4 cm/week
Prenatally, placenta provides _____ g/kg AA to developing fetus
3.5 g/kg AA. Infants lose 0.6-1 gm/kg/day of protein so provide them ASAP
VLBW needs ____ g/kg of protein to maintain intrauterine rates of weight gain and nitrogen retention, but realistically need ____ g/kg to grow
2.8; 3.5-4
GFR reaches adult values after ____
2 years
In utero, kidneys receive ____% of fetal CO, decreases to less than _____% during birth, gradually ______ during first 2 months of age
25%, 5%, increases
Majority of fetal skeletal calcium is acquired during third trimester when placenta actively transports Ca. However, increased intestinal Ca absorption in pregnant women begins in 1st trimester and is maintained throughout pregnancy. This is ______ on Vitamin D
Independent
Fetal calcium homeostasis is ____ of vitamin D and calcitriol, but deficiency postnatally is ______
fetal calcium is independent of vit D / calcitriol, but deficiency will impair postnatally
Fetal calcium levels are ____ than maternal blood
Higher. After birth, transient drop and Ca returns to normal within first 48 hrs of life
In neonate, Ca is absorbed from intestine _____. Later becomes ____.
passively, facilitated by lactose; later becomes active
Formula contains _____ calcium than breast milk
more. Human BM meets Ca requirements for first 6 mo of an infant’s lifeR
recommended daily Ca allowance in first 6 mo of life is _____ mg/day
200 mg/day
Gold standard to measure GFR in adults and children?
inulin clearance
Serum Cr steady state takes _____ for term infants
1-2 weeks. GFR at birth doubles in first two postnatal weeks
Main AA for gluconeogenesis
alanine, glycine, glutamate. (leucine cannot)
Smith Lemli Opitz syndrome
d/o of cholesterol synthesis. DHCR7gene. Elevated plasma 7-dehydrocholesterol value. Dysmorphic, cleft palate, CHD, hypospadias, polydactyly, syndactyly of 2nd-3rd toe
Calcium accretion peaks during _____ weeks GA. Fetus accretes _____ mg/kg Ca / day
32-36 weeks. 100-130 mg/kg Ca / day. Breastfed term infants daily Ca retention is 90 mg so needs fortifier or preterm formula
Coordination of suck swallow breathe improves with age. When does peak vacuum created occur in suck cycle?
Even day 4-5 is > 2-3 days of age of sucking
Peak vacuum when sucking coincides with lowering of newborn’s tongue
Term newborns: 10-30 sucks per burst
Preterm newborns at 32 weeks if 3-5 sucks per burst
Excess of this mineral leads to basal ganglia injury.
Manganese
Manganese deficiency: dermatitis, hair depigmentation, FTT, GI symptoms
What does chromium, copper, molybdenum, zinc toxicity lead to?
Chromium toxicity - chronic renal failure
Copper - liver cirrhosis
Molybdenum - disruption of copper metabolism
Zinc - decreased leukocyte and phagocyte activity
What is cysteine useful for?
Synthesis of anti-oxidant glutathione, helps maintain redox potential, and assists with calcium homeostasis
What does folate do?
important for degradation of AA homocysteine and histidine
Estimated survival time for newborn who was 2 kg and no external nutrient supply?
10 days
1 kg = 4 days
500 g = 2 days
Most common reasons for pump-dependent mothers of preterm neonates to have decrease in established milk supply
infrequent pumping, breast shield with tight fit, progestin based contraception
What do milk banks screen for in terms of ID
HIV, HTLV, hep B + C, syphilis
How much copper to preterm neonates need?
120 mcg/kg/d
Predominant storage site for zinc
bone (40%) and liver (20%)
Highest amount of LCPUFA is in ______
brain and retina
Early hypocalcemia of prematurity
usually asymptomatic. Typically normal by 7-10 days
How much zinc supplementation is required?
350 mcg/kg/day
What ID does pasteurization eliminate?
HIV, CMV
What is prevalence of severe cholestasis with PN between 14-28 days
14%
Lactoferrin + probiotic benefits?
lower incidence of LOS
The negative side of donor milk
associated with decrease in early weight gain compared to preterm formula
what beneficial contents of gastric residuals
contain nutrients, gastric acid, enzymes that are likely beneficial for GI motility and development
Pasteurization eliminates _____
HIV and CMV, IgA, lactoferrin, and lysozymes. Does NOT alter human milk oligosaccharides
Can IV / enteral nutrition in preterm achieve intrauterine accretion rates of LCPUFAs?
NO
What is creamatocrit
estimates amount of lipids and calories in human milk
What is platelet-activating factor acetylhydrolase?
anti-inflammatory component in human milk that degrades platelet-activating factor, which is thought to be involved in NEC development
What is suck ratio in non-nutritive BF?
6-1 to 8-1 (young neonates is 1-1, 2-1)
What is lactoferrin
most common whey protein in milk. In stomach, pepsin assists with proteolysis of lactoferrin, which produces lactoferrin (microbicid). Lactoferrin assists with direct destruction of bacteria, viruses, fungi, and parasites. That’s why H2 antagonists / PPI can interfere with pepsin-induced proteolysis of lactoferrin
Where is phosphorus absorbed? through what mechanism?
active + passive transport in jejunum
Preterm milk does NOT have extra phos (hence need fortifier)
Zinc deficiency
perianal dermatitis, FTT, alopecia, diarrhea, crusted erythematous rash
Benefits of trophic feeds
prevent intestinal atrophy, stimulate GI development, improve gut motility, greater activity of digestive enzymes
Cord blood Mg is _____ than maternal Mg. Where is it stored in fetus?
Cord blood Mg is HIGHER, reflecting active placental transport of Mg
Fetal Mg > maternal Mg. Mostly in bone (65%), then muscle + soft tissues (34%)
5 of what is ingested
Gi only absorbs 40
Intralipid is composed of?
100% soybean
Weight loss during first week for preterm is 10-20% weight loss. From what compartment?
Decrease in TBV is interstitial fluid (TBW, ECF, interstitial fluid). No alteration in plasma volume
Most fetal calcium accretion occurs during third trimester
25-30g by term.
250-300 mg/day
After birth, can only absorb 50-60% intestinal absorption Ca. Need 2x Ca compared to phos.
Zinc intestinal absorption is increased by ______
AA and protein
What is phytate? where is it found?
phytate decreases zinc absorption
found in soy milk, Ca, iron, Mg
Copper deficiency
hypo chromic anemia, neutropenia, osteoporosis, seborrheic dermatitis-like rash, FTT, diarrhea, HSM, hypotonia, apnea
Major long chain PUFA is:
docosahexaenoic acid (22:6, n-3)
lactoferrin protein contains binding sites for
ferric iron, ribonuclease, nucleotide, and heparin, but NOT heme
Omegavan is _____
100% fish oil
Neonates receiving fish oil able to rachieve higher docosahexaenoic acid than were those receiving nonfish oil based emulsions; but immediate decrease in levels after birth not prevented
Frequency of rickets/fractures BW < 1.5 kg and <1 kg
rickets / fractures occurs in 10-32% of neonates with BW < 1.5 kg, and in 50-60% with BW < 1 kg
Osteopenia of prematurity typically has normal Ca, low / normal Phos
Human milk promotes commensal bacteria, which attach to _______, preventing pathogenic bacteria from binding
toll-like receptors
Anti-inflammatory mediators resolvin D1 and protectin D1 are derived from
docosahexaenoic acid (22:6, n-3)
Primary factor in development of bone disease of prematurity is
Vitamin D deficiency
Lipoprotein lipase
glycoprotein mostly found in adipose tissue
Copper absorption is impaired by
enteral intake of ascorbic acid, iron, zinc
Pasteurization eliminates ______, but does NOT affect
Pasteurization eliminates IgM, lipoprotein lipase, bil salt-activated lipase. IgA and IgG decrease slightly. Lactoferrin and lysozyme decrease by a lot
Does NOT affect linoleic acid, FFA, or monoglycerides.
Folate daily intake
400 mcg/day, but only 30% adhere to it
When to initiate iron?
2 weeks of life
How much lipids required to prevent essential fatty acid deficiency? symptoms?
0.5-1 g/kg. Poor growth, scaly skin lesions, visual problems, neuro deficits
