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APEX > Kidney Liver Endocrine > Flashcards

Kidney Liver Endocrine Flashcards

1
Q

Serum osmolarity

A

2 [Na+] + (glucose/18) + (BUN/2.8)

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2
Q

Where is ADH produced

A

Supraoptic and paraventricular nuclei of hypothalamus

RELEASED by posterior pituitary gland

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3
Q

Where is angiotensinogen produced?

A

Liver

Renin converts angiotensinogen to Angiotensin I in the systemic circulation

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4
Q

Where is ACE produced?

A

Lung

Converts ang I to ang II

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5
Q

What does AT II do?

A

Stimulates aldosterone release from the zona glomerulosa in the adrenal glands, also a v potent vasoconstrictor

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6
Q

What’s in the medulla?

A

Loops of Henle and collecting ducts

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7
Q

What’s in the cortex?

A

Most of the nephron: glomerulus, Bowmans capsule, proximal and distal tubules

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8
Q

What’s the difference between aldosterone and ADH?

A

Aldosterone controls extracellular fluid volume: Na+ and H20 are reabsorbed together—> ↑ blood volume but doesn’t change osmolarity —> Na+, H20 reabsorption, K+ excretion

ADH (vasopressin) controls plasma osmolarity: H20 is reabsorbed but Na+ is not

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9
Q

What makes the kidney release EPO? What does EPO do after it’s released?

A
  • inadequate 02 delivery to kidney: anemia, hypovolemia, hypoxia
  • stimulates stem cells in bone marrow to produce erythrocytes
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10
Q

What 3 things induce renin release?

A
  • ↓ renal perfusion pressure
  • SNS activation (beta 1)
  • Tubuloglomerular feedback (↓ Na+ and Cl- in distal tubule)
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11
Q

Compare D1 and D2 receptors

A

D1: kidney, splanchnic circulation: gs receptor
D2: presynaptic adrenergic nerve terminal: gi receptor

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12
Q

Renal blood flow

A

650mL/min to each kidney or 20-25% of CO

Afferent → glomerular capillary bed → efferent → peritubular capillary bed

  • Of blood delivered to kidney only 20% filtered at glomerulus (180L/day), call this ultrafiltrate
  • 99% ultrafiltrate reabsorbed after filtration
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13
Q

GFR

A

125mL/min

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14
Q

Filtration fraction

A

20% of renal blood flow (125/650)

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15
Q

Fraction of ultrafiltrate excreted as urine

A

1%

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16
Q

Best estimation of glomerular filtration rate?

A

Creatinine clearance (mL/min)

Normal 95-150mL/min
Mild dysfunction: 50-80
Moderate dysfunction: 10-25
Very f’d up: <10mL/min

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17
Q

GFR calculation

A

(140-age) x (weight in kg) / (serum crt x 72)

For a woman, multiply the answer by 0.85

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18
Q

Coags and renal disease

A

ESRD can have long bleeding time even with normal platelet, PT, PTT values because uremia impairs platelet function

Treatment = desmopressin (replenishes vWF), can do cryo, but has viral risk

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19
Q

How much renal blood flow is filtered at the glomerulus? Where does the rest go?

A 
RBF = 1000-1250mL/min
GFR = 125mL/min or ~20% RBF

So filtration fraction is 20% - means 20% is filtered by the glomerulus and 80% is delivered to peritubular capillaries

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20
Q

MOA of fenoldapam?

A

Selective Da1 receptor antagonist, ↑ RBF

Low dose 0.1-0.2mcg/kg/min renal vasodilator ↑ RBF, GFR, and facilitates sodium excretion without affecting ABP, may offer renal protection during aortic surgery or CPB

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21
Q

Where do carbonic anydrase diuretics work? Use?

A

Proximal tubule (net loss of bicarbonate and sodium, net gain of H+ and Cl-)

used for open angle glaucoma, altitude sickness, central sleep apnea syndrome

SE: metabolic acidosis, hypokalemia

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22
Q

Where do osmotic diuretics work?

A

Sugars that undergo filtration but not reabsorption - proximal tubule is main site and loop of Henle (inhibit water reabsorption)

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23
Q

Where do loop diuretics work and how

A
  • medullary region of the thick portion of ascending loop of Henle
  • poison the Na/K/2Cl transporter so a ton of Na remains in distal tubule causing a ton of dilute urine to be excreted
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24
Q

Location of action of thiazide diuretics

A

Distal tubule (inhibit the Na/Cl transporter there)

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25
Q

Tests of GFR and normal values

A

BUN 10-20mg/dL

Creatinine 0.7-1.5mg/dL

Creatinine clearance 110-150mL/min

All measure glomerular function

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26
Q

Tests of tubular function

A

Fractional excretion of Na+ (1-3%)

Urine osmolarity 65-1400mOsm/L

Urine sodium conc 130-260mEq/day

Urine spec gravity 1.003-1.030

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27
Q

Which hormones are produced by the kidneys?

A

EPO

Calcitriol (1,25[OH]2) = active D3, under control of PTH

Prostaglandins

  • PgE2 and PgI2 vasodilate renal arteries
  • TxA2 constricts
28
Q

ANS receptors in kidneys?

A

A2: diuresis

B1: renin release

29
Q

Aldosterone: where it’s made, what it does, what triggers release

A

-Produced in the zone glomerulosa of adrenal gland.

↑ Na/K/ATPase in distal tubules and collecting ducts
→ facilitates Na+ and H20 absorption and K+ excretion

Release triggered by:

  • RASS stim
  • Hyponatremia
  • Hyperkalemia
30
Q

ADH

A

PRODUCED by hypothalamus, RELEASED by posterior pituitary
Controls osmolarity

V1 (qi) receptor → potent vasoconstriction
V2 (qs) receptor → ↑ aquaporin-2 channels in collecting ducts

31
Q

Lab tests for liver synthetic function

A

PT, INR, albumin

32
Q

Lab tests for hepatocellular injury

A

AST, ALT, GST

33
Q

Lab tests for biliary obstruction

A

Alk phosphatase and GGTP (GGTP is more specific)

34
Q

Pure glucocorticoids

A

Decadron
Betamethasone
Triamcinolone
(Anti inflammatory + metabolic)

35
Q

Pure mineralocorticoids

A

Aldosterone (sodium retention, potassium excretion)

36
Q

TX thyroid storm

A 
Block synthesis (methimazole, carbimazole, PTU, potassium)
Block release (radioactive iodine, potassium iodide)
Block T4 → T3 conversion (PTU, propranolol)
Beta blocker (propranolol, esmolol)

DON’T give aspirin - it helps fever but it can ↑ free fraction T4 and worsen the situation.

37
Q

When is postoperative hypocalcemia usually evident with inadvertent parathyroid removal

A

24-48 hrs

Happens sometimes after thyroidectomy

38
Q

Best steroid for orthostatic hypotension

A

Fludrocortisone has mineralocorticoid properties 125X cortisol

↑ intravascular volume by promoting salt retention, can help chronic orthostatic hypotension

39
Q

Absolute CI to ECSWL

A 
Pregnancy
Bleeding risk (coagulopathy or anticoagulation)
40
Q

Compelling indicators of renal injury

A

↑ serum creatinine 100%
OU <0.5mL/kg/hr x 12 hrs
↓ GFR >50%

41
Q

Compelling indicators of renal failure

A

↑ serum creatinine 200% or >4mg/dL
↓ GFR >75%
UO <0.3ml/kg/hr x 24 hrs or anuria x 12 hrs

42
Q

TX uremic bleeding

A

Desmopressin is first line

Can also give cryo but ↑ risk viral transmission

↑ bleeding time but other coags normal

43
Q

Hepatic blood flow

A

30% CO (about 1500mL)

Supplied by portal vein and hepatic artery

Portal vein=75% flow, 50% 02
Aorta → splanchnic organs → portal vein → liver

Hepatic artery=25%flow, 50%02
Aorta → hepatic artery → liver

44
Q

Effects of anesthesia on liver blood flow

A

Induction of GA can → ↓ liver blood flow 30-50%

45
Q

Synthetic proteins produced by liver

A

Since the liver produces so many proteins its easier to remember what it DOES NOT produce

  • immunoglobulins :(produced by humoral immune system)
  • vWF, factor III (tissue factor) : produced by vascular endothelial cells

Factor VIII is made in the liver but it’s made by liver sinusoidal cells and endothelial cells, so it’s NOT made by hepatocytes

All other clotting/lysis factors and plasma proteins are made by hepatocytes

46
Q

What is bilirubin an indicator of

A

Hepatic clearance

It’s ↑ in prehepatic, intrahepatic, and cholestatic dysfunction

47
Q

which IA preserves hepatic blood flow the best

A

Isoflurane

48
Q

Etiologies of cirrhosis

A 
ETOH
Alpha 1 antitrypsin deficiency 
Biliary obstruction 
Chronic hepatitis
Hemochromatosis
R sided HF
Wilson disease (genetic copper accumulation)
49
Q

MELD, Child-Pugh

A

MELD: Bilrubin, INR, serum creatinine

Child-Pugh: albumin ascites bilirubin encephalopathy PT

50
Q

CV manifestations of liver disease

A 
↓ SVR, BP
↑ CO
↑ RAAS, ↑ Blood volume
↑ SV02
Diastolic dysfunction
↑ Vd (due to ↓ osmotic pressure)
51
Q

Respiratory manifestations of liver disease

A 
Restrictive defect
↓ compliance
Respiratory alkalosis 
Hepatopulmonary syndrome
Portopulmonary HTN
52
Q

TIPS

A

Shunts blood from portal vein to hepatic vein (outflow vessel)

Hemorrhage is a high risk

53
Q

Bile -site, storage, release

A

Made by hepatocytes, stored by gallbladder, released into duodenum through ampulla of Valter

Absorbs DAKE (fat soluble vitamins)
Excretory pathway for bilirubin and other products of metabolism
Alkalizes duodenum
54
Q

Etiologies of SIADH

A

TBI (most common)
Cancer
No cancer lung disease
Carbamazepine

Fluid overloaded dilutional hyponatremia

55
Q

Etiologies of DI

A

Pituitary surgery (most common)
TBI
SAH

Polyuria

Give DDAVP or vasopressin, supportive

56
Q

How does cortisol mitigate the inflammatory cascade

A

Stabilizes lysosomal membranes and ↓ cytokine release

57
Q

Drug of choice for Addison’s

A

Prednisone - it’s an analogue of cortisol. Glucocorticoid : mineralocorticoid is 4: 0.8

58
Q

Who should get stress dose steroids

A

Anyone who has gotten 5->20mg prednisone day for >3 weeks

59
Q

Stress hydrocortisone dosing

A 
Minor surgery (hernia, colonoscopy) 25mg IV
Moderate surgery (colon, joint, TAH) 50-75mg, taper over 1-2 days
Major surgery (CV, thoracic, liver, whipple) 100-150mg IV taper over 1-2 days
60
Q

Sulfonylurea oral diabetes drugs

A

All end in “ide”

Avoid if sulfa allergy, carry risk of hypoglycemia

61
Q

When does NPH peak

A

4-12 hrs

2 hr onset

62
Q

When does regular insulin peak

A

2-4 hrs

30 min onset

63
Q

Signs of excess glucocorticoid secretion

A 
Osteoporosis
Muscle weakness
Weight gain
Mood changes
Immunosuppression
64
Q

Signs of excess mineralocorticoid activity

A

HTN
Hypokalemia
Metabolic alkalosis

65
Q

Etiologies of hypoalbuminemia

A 
Infection
Nephrotic syndrome
Malignancy
Burn
Malnutrition
Liver disease

APEX (11 decks)

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