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Lab Modules > Module 5 - Renal > Flashcards

Module 5 - Renal Flashcards

1
Q

What are some renal function tests?

A

sCr (eGFR and ACR)

Urea (Uric acid)

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2
Q

What are some types of anemia in renal disease?

A

Hgb (Ferritin and iron)

%tSat (TIBC)

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3
Q

What are some functions of the kidney?

A
  • Maintain H20 balance and plasma volume
  • Maintain osmolality of body fluids
  • Maintain acid-base balance
  • Regulate ECF (extracellular fluid) ions
  • Producing renin (RAAS)
  • Production of erythropoietin
  • Activation of vitamin D
  • Excretion of waste products (urine)
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4
Q

What is the reason for the following lab abnormality:

Uremia (increased urea in blood)

A

retention of waste products

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5
Q

What is the reason for the following lab abnormality:

Metabolic acidosis (low pH, low HCO3)

A

can’t secrete H+ ions, can’t regulate bicarbonate (HCO3-)

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6
Q

What is the reason for the following lab abnormality:

Hyperkalemia (increased K+)

A

inadequate tubular secretion

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7
Q

What is the reason for the following lab abnormality:

sodium imbalances

A

kidneys cannot adjust excretion/retention

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8
Q

What is the reason for the following lab abnormality:

Phosphate and calcium imbalances (increased phosphate, decreased calcium)

A

kidneys cannot eliminate PO4 or reabsorb Ca2+, unable to activate vitamin D

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9
Q

What is the reason for the following lab abnormality:

Loss of plasma proteins (albuminuria) and glucose (glycosuria)

A

leaky glomerular membrane

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10
Q

What is the reason for the following lab abnormality:

Unable to concentrate urine (decreased urine Osmol)

A

impaired countercurrent system in loop of henle

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11
Q

What is the reason for the following lab abnormality:

Anemia (decreased Hgb, RBC, Act)

A

Inadequate erythropoietin production

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12
Q

List 3 ways to determine renal function

A
  • Inulin or iothalamate clearance
  • Serum creatinine and calculations
  • 24-hr urine collection
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13
Q

What enzyme converts creatine to creatine phosphate (and vice versa) ?

A

creatine kinase

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14
Q

What is sCr (serum creatinine) ?

A

A nitrogen-containing, non-protein byproduct of muscle

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15
Q

sCr has an _____ relationship with kidney function

A

inverse

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16
Q

increased sCr = _____ renal function

A

decreased

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17
Q

Why does sCr increase in impaired renal function?

A

due to impaired excretion

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18
Q

sCr is used in equations to calculate ______ ________ and to estimate ____

A

creatinine clearance, GFRe

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19
Q

Why can elderly individuals have higher sCr?

A

due to decline in renal function

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20
Q

Why can elderly individuals have decreased sCr?

A

due to muscle wasting or malnutrition

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21
Q

_____ have higher muscle mass

A

males

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22
Q

What ethnicity has higher muscle mass?

A

African Americans

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23
Q

How does increased muscle mass affect creatinine production?

A

causes increased creatinine production

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24
Q

How does decreased muscle mass affect creatinine production?

A

less creatinine production

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25
Q

How does malnutrition affect serum creatinine?

A

malnourished patient may have low protein intake and may have muscle wasting

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26
Q

How does veganism/vegetarianism affect serum creatinine?

A

reflects relative protein intake

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27
Q

How do medications such as cimetidine, trimethoprim, probenecid, dronedarone, and tenefovir affect sCr?

A

increase sCr due to reduced tubular secretion of creatinine

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28
Q

How do medications such as methyldopa, cefoxitin, and flycytosine affect sCr?

A

decreases sCr because it interferes with the serum creatinine assay

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29
Q

What assumptions does the Cockcroft and Gault equation make?

A
  • Assumes normal adult body weight (no extremes such as morbid obesity or cachexia)
  • Assumes sCr is STABLE (not in acute renal failure or renal transplant patients)

-NOTE: Some institutions use 80 as a multiplier (vs. 88.4) due to standardization of sCr analysis (IDMS

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30
Q

What is eGFR?

A

Estimated Glomerular Filtration Rate:

-Using gender, age, ethnicity, and sCr, eGFR is calculated using the MDRD equation

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31
Q

When should MDRD equation be used?

A

should only be used in impaired renal function (<60 mL/min)

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32
Q

MDRD _______ renal function in patients with normal renal function

A

underestimates

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33
Q

If a patient has good renal function, what will the lab report?

A

> 60 mL/min

*it will not report a definite number

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34
Q

What drugs cause afferent vasoconstriction (which will decrease pressure, filtration, and GFR)?

A

PG inhibitions: NSAIDS

Direct constriction: cyclosporine, tacrolimus, contrast dyes, pressors

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35
Q

What drugs cause efferent vasodilation (which will decrease pressure, filtration, and GFR)?

A

ACEI/ARBs

Diltiazem, verapamil

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36
Q

What is urea? Describe it.

A
  • Breakdown product of proteins (amino acids)

- 50% reabsorbed, 50% excreted in urine

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37
Q

Describe urea in dehydration

A

In dehydration, reabsorption of Na+, Cl-, and H2) occurs and therefore urea follows (increased urea)

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38
Q

Describe urea in renal disease

A

In renal disease, can’t eliminate urea (buildup) called uremia

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39
Q

Urea can be used with sCr to determine cause of ______ _________

A

renal abnormalities

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40
Q

What can cause elevated urea?

A
  • High protein diet
  • Renal disease
  • Upper GI bleeding
  • Dehydration
  • Medications
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41
Q

What can cause decreased urea?

A
  • Malnourished
  • Vegetarian/vegan diet
  • Fluid overload
  • Liver damage
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42
Q

What can be used to determine the type of renal failure?

A

urea:creatinine ratio

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43
Q

When should urea:creatinine ratio not be used?

A

if both urea and sCr are within normal limits

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44
Q

Using Canadian measurements for urea:creatinine ratio, what does it mean if it is 100:1 ?

A

Pre-renal: decreased renal blood flow (more urea reabsorbed) or increased urea production

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45
Q

Using Canadian measurements for urea:creatinine ratio, what does it mean if it is 40-100:1 ?

A

Normal or post-renal: obstruction, therefore less outward flow and more urea is reabsorbed

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46
Q

Using Canadian measurements for urea:creatinine ratio, what does it mean if it is <40:1 ?

A

Intra-renal: damage within the kidney, can’t reabsorb urea (lowers ratio)

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47
Q

When do signs and symptoms of uremia develop ?

A

usually in ESRD (eGFR < 15 mL/min)

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48
Q

What are signs and symptoms of uremia?

A
  • N/V
  • fatigue
  • anorexia/weight loss
  • muscle cramps
  • pruritus
  • changes in mental status (confusion)
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49
Q

What are signs and symptoms of uremia in SEVERE cases?

A
  • seizures
  • coma
  • cardiac arrest
  • spontaneous bleeding
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50
Q

Are urea and uric acid the same thing?

A

no way man

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51
Q

What is increased urea called?

A

uremia

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52
Q

What is increased uric acid called?

A

uricemia

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53
Q

What is a buildup of uric acid called?

A

hyperuricemia

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54
Q

What does a buildup of uric acid lead to?

A

crystallization, inflammation and then gouty arthritis, renal stones, tophaceous deposits

55
Q

What are some endogenous causes of uric acid build up?

A
  • renal failure
  • disorders associated with nucleic proteins (i.e. hemolytic anemia, cancer, psoriasis)
  • endocrine disorders
  • acidosis (lactic, keto, alcoholic)
  • genetics
56
Q

What are some exogenous causes of uric acid build up?

A
  • medications

- diet (purine rich)

57
Q

What are examples of drugs that increase uric acid through interfering with renal clearance of uric acid ?

A

Low dose salicylate, pyerazinaide, ethambutol, niacin, ethanol, cyclosporine, acetazolamide, hydrazine, furosemide, thiazide diuretics

58
Q

What are examples of drugs that increase uric acid through increasing turnover rate of nucleic acids

A

Cancer chemotherapies (methotrexate, vincristine, 6-mercaptopurine, azathioprine)

59
Q

Describe the Canadian goal of uric-acid lowering therapy

A

<357 umol/L

*if they have presence of top then <297 umol/L

60
Q

How much should we lower uric acid each month to prevent a gouty attack?

A

59-119 umol/L per month

61
Q

What is the concentration at which uric acid saturates extracellular fluids?

A

405 umol/L

62
Q

During an acute gout flare, how do uric acid levels change?

A

may be low or normal due to the release of cytokines during the acute flare

63
Q

When is the best time to determine uric acid levels?

A

> 2 weeks after subsidence of an acute gout flare

64
Q

Monitor serum uric acid levels every ____ weeks during uric acid lowering therapy titration, then every ___ months once the target uric acid level is achieved.

A

2-5 weeks

6 months

65
Q

How can kidney disease cause anemia?

A
  • decreased erythropoietin
  • decreased RBC production in bone marrow (erythropoiesis)
  • causes anemia
66
Q

What is transferrin saturation (%tSat) ?

A
  • The percentage of transferrin (iron transport protein) that has iron bound to it
  • Calculated using iron and TIBC from measured lab values
67
Q

What is the normal %tSat ?

A

33%

68
Q

In iron deficiency anemia, iron is ____

A

low

69
Q

In iron deficiency anemia, TIBC is _____

A

high

70
Q

In iron deficiency anemia, %tSat is ____

A

low

71
Q

Anemia in renal disease:

Target for Hgb

A

110 g/L

Range 100-115 g/L

72
Q

Anemia in renal disease:

Why do we monitor Hgb?

A

Higher hemoglobin levels (in the normal range) can increase the risk of stroke and CV events in renal disease patients. EPO also carries a cancer risk.

73
Q

Anemia in renal disease:

How often do monitor hemoglobin?

A

Monthly if starting or changing EPO, every 3 months if stable on EPO therapy

74
Q

Anemia in renal disease:

Target for %tSat

A

> 20%

75
Q

Anemia in renal disease:

_____ supplementation is usually tried before initiating EPO in an attempt to increase hemoglobin. (Usually IV)

A

Iron

76
Q

Anemia in renal disease:

Ferritin targets

A

ND-CKD and PD:
>100 umol/L

HD:
>200 umol/L

77
Q

Anemia in renal disease:

Iron target

A

7-27 umol/L

78
Q

Anemia in renal disease:

TIBC target

A

47-80 umol/L

79
Q

Anemia in renal disease:

What are required to calculate %tSat ?

A

iron and TIBC

80
Q

Anemia in renal disease:

When should you monitor ferritin, iron and TIBC?

A

Every 1-3 months

Takes time to build up iron stores

81
Q

Bone Metabolism Abnormalities in renal disease:

Is phosphate usually high or low?

A

High

82
Q

Bone Metabolism Abnormalities in renal disease:

Why is phosphate high?

A

cannot eliminate phosphate, PTH mobilizes phosphate from bone to blood

83
Q

Bone Metabolism Abnormalities in renal disease:

Is calcium usually low or high?

A

usually low but can also be high

84
Q

Bone Metabolism Abnormalities in renal disease:

Explanation for low calcium

A

cannot reabsorb calcium, low activated via D causes reduced calcium absorption in the gut

85
Q

Bone Metabolism Abnormalities in renal disease:

Explanation for high calcium

A

due to longstanding high PTH with mobilization of calcium from bone to blood, or from calcium-containing phosphate binders (i.e. calcium carbonate)

86
Q

Bone Metabolism Abnormalities in renal disease:

Is PTH high or low?

A

high

87
Q

Bone Metabolism Abnormalities in renal disease:

Why is PTH high?

A

release triggered by low calcium levels and impaired vitamin D synthesis

88
Q

Is phosphorus, calcium and PTH is high what do we do?

A

Add non-calcium containing phosphate binder; wait for PTH to come down by itself

ex. sevelamer

89
Q

What do we do if phosphorous is high, calcium is low/normal and PTH is normal?

A

Add calcium-containing phosphate binder - especially if calcium is low

ex. calcium carbonate

90
Q

What do we do if phosphorus is high, calcium is normal/low and PTH is high?

A

Add calcium-containing phosphate binder, add activated vitamin D to bring down PTH and increase calcium absorption in the gut

ex. calcium carbonate and calcitriol

91
Q

What do you do if phosphorus is normal and PTH and calcium are high?

A

Add a calcimemetic. Decreases calcium and will bring down PTH

ex. cinacalcet

92
Q

The kidneys are responsible for ___% elimination of potassium.

A

90%

Renal disease leads to accumulation of K+

93
Q

How does insulin affect K+?

A

Insulin stimulates Na-K-ATPase pump to drive K+ into cells

94
Q

How does epinephrine affect K+ ?

A

Stimulates B-receptors - activates Na-K-ATPase Pump

95
Q

How does Aldosterone affect K+ ?

A

Promote the reabsorption of Na+ and H20 (in exchange for K+ which is excreted in the urine) in the distal tubule and collecting duct

96
Q

How does acid-base status affect K+ ?

A

Complex process:

  • metabolic alkalosis (decreases K+)
  • metabolic acidosis (increases K+ but overall neutrality)
97
Q

Describe aldosterone and potassium homeostasis

A

1) Increases effects of Na+K+ ATPase
2) Makes K+ channels so MORE potassium is excreted in the urine
3) Makes Na+ channels so more Na+ (and water follows) is reabsorbed into the blood (volume expansion and increased blood pressure)

98
Q

Describe the treatment interventions for severe hyperkalemia (emergency treatment)

A
  • Calcium gluconate 10% 500-1000mg (50-100mL) over 2-3 mins for cardiac stabilization
  • Regular insulin 10-20 units with 25-50 g glucose
  • Salbutamol 10-20 mg nebulizer or 1200 mpg (12 puffs) by spacer over 2 mins
  • Hemodialysis (removes 25-50 mmol/K/hr)
99
Q

Describe the treatment interventions for mild hyperkalemia

A
  • Diuretics (thiazide if CrCl > 30 mL/Min, furosemide if CrCl < 30 mL/min)
  • Kayexalate (sodium polystyrene sulfonate 15-30 g PO q4-6h
100
Q

What is included in macroscopic analysis?

A

-color and appearance

101
Q

What is included in microscopic analysis?

A
  • cells (RBCs, WBCs)
  • casts
  • crystals
102
Q

What is included in chemical analysis?

A
  • specific gravity
  • pH
  • leukocyte esterase
  • nitrite
  • protein
  • glucose
  • ketones
  • urobilinogen
  • bilirubin
  • blood (Hgb)
103
Q

What is a urine dipstick test?

A

-Chem-Strip dipped in urine

104
Q

Is a urine dipstick qualitative or quantitative ?

A

Semi-quantitative:

  • Qualitative: positive/negative
  • Quantitative: color represents a number or quantity of a specific parameter
105
Q

List some possible abnormalities for a UTI that would show on a urine dipstick test

A

cloudy, WBCs, casts/blood, leukocyte esterase+, nitrite+

106
Q

List some possible abnormalities for Diabetes that would show on a urine dipstick test

A

proteinuria, glycosuria, ketones )DKA_

107
Q

List some possible abnormalities for renal disease that would show on a urine dipstick test

A

proteinuria, reduced specific gravity, renal stones (crystals)

108
Q

List some possible abnormalities for hepatic disease/damage that would show on a urine dipstick test

A

urobillinogen increased, bilirubin

109
Q

Describe microscopic urine analysis (for UTI’s)

A

1 mL urine centrifuged and the sediment is examined under a microscope

110
Q

How will the following parameter be affected if they have a UTI:

RBC

A

> 1-2 cells/hpf

111
Q

How will the following parameter be affected if they have a UTI:

WBC

A

large numbers (>30/hpf)

112
Q

How will the following parameter be affected if they have a UTI:

Microorganisms

A

present

113
Q

How will the following parameter be affected if they have a UTI:

casts

A

can be present in pyelonephritis

114
Q

How will the following parameter be affected if they have a UTI:

crystals

A

positive or negative (indicates renal calculi)

115
Q

How will the following parameter be affected if they have a UTI:

appearance, colour

A

cloudy, may be orange/red if blood present

116
Q

How will the following parameter be affected if they have a UTI:

specific gravity

A

within normal limits

117
Q

How will the following parameter be affected if they have a UTI:

pH

A

varies; may be acidic or alkaline, should be kept more acidic for treatment

118
Q

How will the following parameter be affected if they have a UTI:

protein

A

negative or positive

119
Q

How will the following parameter be affected if they have a UTI:

glucose

A

negative

120
Q

How will the following parameter be affected if they have a UTI:

ketones

A

negative

121
Q

How will the following parameter be affected if they have a UTI:

bilirubin

A

negative

122
Q

How will the following parameter be affected if they have a UTI:

blood

A

positive (damage)

123
Q

How will the following parameter be affected if they have a UTI:

leukocyte esterase

A

positive (esterase activity of leukocytes in the urine - fighting bacteria)

124
Q

How will the following parameter be affected if they have a UTI:

nitrite

A

positive (bacteria reduce nitrates)

125
Q

If the blood glucose level exceed the _________ capacity of the proximal tubule, glucose will appear in the urine

A

reabsorption

126
Q

The blood level at which tubular reabsorption of glucose stops is about _____ mmol/L

A

9-10

127
Q

Urine glucose is most common in patients with ______ (not used to diagnose)

A

diabetes

128
Q

What do urine ketones indicate?

A

Uncontrolled Type 1 diabetes = diabetic ketoacidosis

*Deficiency of insulin causes derangement of carbohydrate metabolism which causes free fatty acids used as energy source

129
Q

Other than diabetes, when can urine ketones occur?

A

can also occur in pregnancy, carb-free diets, starvation and alcoholism

130
Q

What are some sings and symptoms of ketoacidosis ?

A
  • headache/confusion
  • seizures/coma
  • nausea/vomiting
  • ab pain
  • hyperglycemia
  • increased anion gap
  • metabolic acidosis
131
Q

What does excessive protein in the urine indicate?

A

the glomerulus is losing its filtering capability

132
Q

What is ACR (albumin-creatinine ratio) used in the diagnosis of?

A

diabetic nephropathy and/or to monitor kidney disease progression

133
Q

What urine sample is the best for ACR?

A

early morning urine sample

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