module 12 acute tubular necrosis and CKD

Question 1

acute tubular necrosis mortality predictors

Answer 1

oliguria
high severity of illness
acute MI
stroke
seizure
chronic immunosuppression
need for ventilation

Question 2

ATN prodromal phase

Answer 2

insult to kidney has occured

Question 3

ATN oliguric phase

Answer 3

2-8 weeks with UO of 50-400mL/day
oliguria and progressive uremia; dec. GFR, hypervolemia
- fluid excess, inc. K, uremic syndrome
dialysis may be required

Question 4

ATN postoliguric phase

Answer 4

diureses; tubular function impaired and azotemia continues
fluid volume deficit until kidneys recover
- 2-10 days, up to a year
full recover: BUN/creatinine normal

Question 5

prerenal lab findings AKI

Answer 5

SG: >1.020
BUN/creatinine ratio: >20:1
urine Na: < 10
urine sediment: few hyaline casts

Question 6

intrarenal lab findings AKI

Answer 6

possible proteinuria
SG: 1.010-1.020
BUN/creatinine ratio: 10-20:1
urine Na: >20
urine sediment: tubular, RBC, and WBC casts

Question 7

ATN patho

Answer 7

ischemia or nephrotoxin 
Inflammation and tubular injury
-> inflammatory cells
-> cast formation
-> tubular obstruction 
-> inc. tubular intra-luminal pressure 
-> tubular backleak, oliguria, dec. GFR
dec. O2 to outer medulla -> vasoconstriction

Question 8

ATN tubule cell injury Reversible patho

Answer 8

• loss of polarity
• > inc. distal Na
• > inc. tubuloglomerular feedback
• > vasoconstriction
• > dec. GFR and oliguria
• detachment
• > obstruction by casts and tubular back leak
• > inc. intratubular pressure and dec. tubular flow
• > dec. GFR and oliguria

Question 9

ATN tubule cell injury irreversible patho

Answer 9

necrosis and apoptosis

• > tubular back leak
• > dec. tubular flow
• > dec. GFR and oliguria

Question 10

ATN endothelial dysfunction patho

Answer 10

vasoconstriction

• > RAAS
• > inc. endothelin, dec. NO, dec. PGI2
• > dec. GFR and Oliguria

Question 11

CKD progressive process

Answer 11

chronic kidney disease -> chronic renal failure -> end-stage renal disease
- ESRD: requires dialysis
Linked with comorbidities
- HTN, DM
dec. kidney function or kidney damage of 3 mo.
GFR < 60mL/min for 3 mo.

Question 12

GFR reduction occurs with

Answer 12

nephron loss

kidneys compensate until 75-80% of nephrons are damaged/nonfunctional

Question 13

stages of CKD

Answer 13

each stage higher the GFR and kidney function dec.

1-5

Question 14

Stage 1 and 2 CKD

Answer 14

labs normal
asymptomatic with some kidney disease
minimizing risk factors
initial decrease in GFR

Question 15

stage 3 CKD

Answer 15

symptoms may appear and treatment may be needed.

HTN

Question 16

Stage 4 CKD

Answer 16

planning for dialysis or transplant should begin

s/s very apparent

Question 17

Stage 5 CKD

Answer 17

Renal replacement therapy needed or death will ensue

Question 18

CKD risk factors

Answer 18

DMT2
HTN
recurrent pyelonephritis 
glomerulonephritis
polycysitic kidney disease
family hx 
exposure to toxins
>65
ethnicity: black, white, mexican-american 
electrolyte  and fluid imbalance

Question 19

stages of CKD according to nephron loss

Answer 19

dec. renal reserve
- <75% nephron loss
- no s/s, BUN/creatinine nml
Renal insufficiency
- 75-90% nephron loss
- polyuria, nocturia, slight in. BUN/creatinine
- control with diet and medication
End stage:
- >90% nephron loss
- azoztemia/uremia, fluid and electrolyte abnomal, osteodystrophy, anemia, dialysis or transplant needed.

Question 20

CKD and primary foci

Answer 20

appropriate management of ATN
blood glucose control
aggressive management of HTN

Question 21

HTN, cardiovascular disease, and CKD

Answer 21

Hypervolemia, escalated atherosclerosis, inc. RAAS/SNS activity
cardiovascular disease is both a risk factor and side effect of CKD

Question 22

metabolic acidosis and CKD

Answer 22

kidneys dont secrete H+
will be exchanged for intracellular K+
-> hyperkalemia and dec. pH
Kidney does not produce Bicarb -> dec. pH

Question 23

uremic syndrome

Answer 23

retention of metabolic wastes -> impaired healing

Question 24

electrolyte imbalance and CKD

Answer 24

retained K+, phosphorus, mag

loss Ca

Question 25

Bone and mineral disorders and CKD

Answer 25

inc. phosphorus and PTH -> bone/mineral metabolism
kidneys unable to reabsorb calcium
unable to activate Vit. D -> Ca only available from the bones

Question 26

malnutrition, pain, depression and CKD

Answer 26

hypoalbuminemia

Question 27

anemia and CKD

Answer 27

lack of erythopoietin (secreted by kidney in response to hypoxia)
uremia shortens RBC life

Question 28

dialyasis

Answer 28

remove metabolic wastes and correct fluid and electrolyte imbalances
primary reason: development of uremia or hyperkalemia unresponsive to other tx.

Question 29

extra-renal manifestations of CKD

Answer 29

HTN
- renin release r/t damaged kidney or inc. intravascular volume r/t abnormal handling of Na and H2O. 
Lungs and pleura: 
- chronic pulm. edema
Immune system:
- depressed, delayed immune response
GI: 
- N/V, and anorexia
Anemia
- dec. EPO, dec. RBC survival, poor nutrition, bleeding
Nervous system: 
- AMS, sensory and motor neuropathy common with uremia