Part 30 Flashcards
Edema definition
Palpable swelling produced by expansion of insterstitial fluid volume in the tissue itself
Pitting vs nonpitting edema
Pitting edema leaves an indentation when pressed with a finger and indicates less severe fluid buildup, nonpitting edema bounces back from indentation when pressed with a finger and indicates severe fluid buildup
Anasarca definition
Massive and generalized fluid build up, extreme edema
Capillary hydrostatic pressure definition
Pressure pushed on the capillary walls due to blood pressure to release fluid into the tissue bed, increased in cases of inflammation and venous congestion
Capillary osmotic pressure definition
The pressure pulling water back into the capillary vessel due to plasma proteins within the vessel
Lymphatic obstruction and it generally manifests ___laterally
Tumors, parasites, fibrosis, or removal of lymph nodes that cause obstruction of the flow and edema, generally manifests unilaterally
Interstitial osmotic pressure definition
The pressure Inward pulling force of fluid from the capillary into the interstitial space where proteins drive the fluid
Interstitial hydrostatic pressure
The pressure pushing fluid out of the interstitial space and back into the capillaries
Cardiac signs of generalized edema (5)
- dyspnea upon exertion
- paroxysmal nocturnal dyspnea
- JVD
- displaced apical pulse
- cool extremities
Cardiac labs of generalized edema, how is BUN/Cr ratio? How is sodium level? How is BNP level?
Elevated BUN/Cr ratio
- Decreased Na+
- Elevated BNP
Brain natriuretic peptide (BNP) definition
A protein released in the body when the heart is working very hard and failing
Often a patient with paroxysmal nocturnal dispnea will have to do this to sleep
Prop pillows underneath them
Hepatic signs of generalized edema (4)
- history of alcohol abuse
- ascites
- jaundice
- asterixis
Ascites definition
Excessive fluid retention in peritoneal space, often resulting from portal hypertension, has large tortuous veins called caput medusa
Asterixis definition
Flapping fingers when holding hand outright due to nervous system effect
Renal signs of generalized edema (4)
- Uremia
- metalic or fishy taste
- uremic frost
- elevated BP
- periorbital edema
Uremic frost definition
Uremic crystal formation on skin due to renal failure, smells foul
Renal labs of generalized edema, how is albuminuria? RBC count? K+ levels?
- Positive for albuminuria
- Normocytic anemiaRBC count
- Hyperkalemic
Edema can be caused by increased hydrostatic pressure caused by these 2 mechanisms
1) impaired venous return
2) arteriolar dilation
Edema can be caused by reduced plasma osmotic pressure caused by these 3 mechanisms
1) protein losing gastroenteropathy or glomerulopathy
2) liver cirrhosis
3) Malnutrition
Edema can be caused by lymphatic obstruction caused by these 3 mechanims
1) inflammation
2) post surgical
3) post irradiation
Edema can be caused by increased capillary permeability or sodium retention caused by these 2 mechanisms
1) exccess salt intake or reabsorption
2) inflammation/immune rxn
Hydrothorax definition
A type of edema with accumulation of excess fluid in chest cavity
Hydropericardium definition
A type of edema with fluid in the pericardial sac that can lead to compression of heart
Exudate definition
A type of edema with inflammatory fluid spilling out of skin
Some common causes of anasarca (4)
- nephrotic syndrome
- cirrhosis
- myxedema (hypothyroidism)
- anaphylaxis
Nephrotic syndrome can cause edema because of the…
….massive proteinuria diminishing the colloid oncotic pressure
An early and a late finding in cirrhosis
Early - telangiectasias, broken sensitive vessels seen on face
Late - jaundice
A left sided congestive heart failure sees back up in the ___ while a right sided sees backup in the _____
lungs, extremities
Dependent edema definition
Edema that works with gravity via venous insufficiency and failure of valves causing blood to pool in veins increasing venous pressure and leading to edema that usually resovles when legs are elevated
Dependent edema treatment (3)
- restricted sodium intake
- stockings
- weight loss
Brawny edema definition
Edema caused by chronic venous insufficiency causing thickened, dark colored skin with pectachiae and ulcerations
Idiopathic cyclic edema definition and treatment
Edema that occurs on a predictable cycle possibly related to hormones, normally seen in female menstrual cycle with weight change during day around period
Treated with sodium restriction or diuretics with caution
Drug class known to be a source of edema
Calcium channel blockers
If edema is worse in the morning, think of ___ edema origin
Renal
Facial involvement of edema, think of one of these 3 types involvement
- renal
- myxedema
- allergic
Increased edema at end of day improving at night think of ___ edema origin
Cardiac
What type of edema is often treated with stockings?
Dependent edema
How does cirrhosis of liver progress regarding edema?
To ascites then to generalized edema
Nephrotic syndrome definition
Kidney disorder that causes excretion of too much protein in the urine resulting from damage to the glomeruli, with the predominant protein being found being albumin
When albumin leaks into urine, the blood loses ____ pressure, which can result in ___
Plasma osmotic, edema
Normal urinary protein excretion should be less than ___mg/day
150
Common causes of transient proteinuria (3)
- Exercise
- Fever
- UTI
Persistent proteinuria definition
Protein excretion greater than 150mg/day on 2 more more occassions
A positive urinalysis for proteinuria indicates urinary protein excretion above ___mg/day. A urine dipstick only measures what protein?
300, albumin
Nephrotic syndrome range is when proteinuria loss is greater than ___mg/day
3500
3 symptoms of nephrotic syndrome
- hyperlipidemia
- hypoalbuminemia
- edema of legs feet and ankles
Orthostatic proteinuria definition, how do we test for it?
A condition characterized often in children by increased protein excretion in the upright position, but normal protein excretion after periods of laying flat. 1st urine collection in the morning is the best way to test for it
Nephrotic range proteinuria test and confirmatory diagnostic test
24 hr urine sample, diagnosis confirmed by a kidney biopsy
Primary vs secondary nephrotic syndrome
Primary has an absence of identifieable systemic disease
Secondary has presence of identifiable systemic disease causing damage to the kidneys (diabetes, SLE, amyloidosis)
6 sources that account for 90% of nephrotic syndrome
- minimal change disease (childhood onset)
- Focal segmental glomerulosclerosis
- membranous glomerulopathy
- membranoproliferative glomerulonephritis
- diabetic neuropathy (most common in US)
- amyloidosis
Minimal change disease accounts for majority of cases of nephrotic syndrome in this population
Children under 10
Minimal change disease symptoms (3)
- Severe edema
- ascites
- pleural effusions (crackles heard on PE)
Minimal change disease pathophysiology
Often idiopathic, potentially immunologically mediated and related to abnormal T cell function
Minimal change disease treatment and prognosis
Corticosteroid therapy, excellent prognosis
Focal segmental glomerulosclerosis (FSGS) definition
Scarring of the glomeruli of the kidney resulting in decreased renal function and eventually failure
Focal segmental glomerulosclerosis treatment and prognosis
Corticosteroids, very poor, high rate of progression to end stage renal disease
Membranous nephropathy definition, what disease is it most commonly associated with?
-An often autoimmune reaction in the glomeruli’s basement membrane that results in decay in renal function, most commonly associated with nephrotic syndrome in adults
What does the sediment of centrifuge urine contain?
- RBCs
- WBCs
- RBC casts
- Lipids
- WBC casts
Membranoproliferative glomerulonephritis definition, typical presentation (what do we see in sediment?)
An abnormal antibody response where immune complexes build up in the basement membrane of the glomeruli causing damage
Typically see RBC casts, lipidemia, etc in the analysis
1 systemic disease causing nephrotic syndrome
Diabetic glomerulosclerosis
Treatment for nephrotic syndrome induced edema cannot be treated by just adding more fluids. Why?
-This won’t fix the pressure gradient that is missing as a result of proteinuria, it will just put strain on the heart and exacerbate the problem
Why is hypothyroidism seen in nephrotic syndrome? Why does nephrotic syndrome put an individual at risk for infection? Why is it a hypercoaguable state?
Thyroid hormone leaves with the proteins out to the urine/periphery
Some immunoglobins are also lost to the periphery/urine
It involves a loss of antithrombin III, protein C causes a risk of hypercoaguability
Frothy urine even aftersitting for a period of time is indicative of…
…high proteinuria and potentially nephrotic syndrome
Nephrotic syndrome hyperlipidemia (oval fat bodies) mechanism of action
Decreased oncotic pressure and hypoalbuminemia causes increased hepatic synthesis of proteins and lipids concurrent with decreased peripheral metabolism
Nephrotic syndrome may lead to metabolic ___ (acidosis or alkalosis?
alkalosis
Serum creatinine will not be a good marker for gross renal function in ___ renal impairment
early
Azotemia definition
Higher than normal level of blood urea nitrogen, might be indicative of kidney’s inability to excrete these compounds
Membranous glomerulopathy treatment
Corticosteroids
What drugs should be avoided in the treatment of nephropathies
- ASA
- NSAIDS
- certain antibiotics
Edema dietary management
Decrease Na+
fluid restriciton if hyponatremic
Decrease fat
Adequate protein in diet
Drug indicated for nephrotic syndrome treatment
Prednisone
Total body water (TBW) definition
The summation of all the different forms of water in the body, approx 60% of body weight in males and 50% in females
Intracellular fluid definition
Summation of fluid that lies intracellularly in the body, composes 40% of total body weight or 2/3 of total body water
Extracellular fluid definition
Summation of fluid that lies extracellularly in the body, composes 20% of total body weight or 1/3 of total body water
Intravascular space definition
Summation of fluid that lies within the vessels as part of extracellular fluid and composes 25% of extra cellular fluid or 5% of total body weight
Interstitial space definition
Summation of fluid that lies within the body between cells as part of extracelluar fluid and compses 75% of extracellular flulid or 15% of body weight
Osmosis definition
Movement of water from low solute conc. to higher solute conc. passively to attain equilibirrum
Total body water is directly related to ___ and inversely related to ____. Infants, for example…
Lean body mass, fat content
…have higher percentage of body water because not as much fat
Arterial vs venous end of vessel filtration vs absorption state
At arterial end hydrostatic pressure is greater than plasma osmotic pressure (which is constant), resulting in net filtration, hydrostatic pressure progressively drops off eventually causing favor of absorption from plasma osmotic pressure on venous side
Osmolality definition
of milimose of solute particles per liter of solution, the greater the osmolallity the stronger urge water has to dilute the material
A very frequent cause of death in hospitalization is cerebral edema, this is when individuals vessels become ___tonic to the tissue surrounding them causing fluid buildup in the brain tissues
Hypo
Hypertonic by definition means ___solute compared to fluid, hypo means ____
more, less
Sensible water losses vs insensible water losses
Sensible losses are measurable and take the form of urine, include 1-2 L per day. Insensible loss is immeasurable and due to evaporative loss thru skin and respiratory tract and includes of to 600-900mL/day
3 factors that increase insensible losses
- add 10% for each degree of fever above 99 degrees
- increase with tracheostomies
- decrease with humidified ventilatory support
Daily sodium intake required, daily potassium intake required, why does hyperkalemia kill?
1 to 2 MEQ/kg/day
.5-1 MG/kg/day
Hyperkalemia causes arrhythmia and can stop a heart beat
Na+ HCO3-, and cl- are predominantly stored in ___cellular fluid, while K+, Mg2+, protein, and phosphates are stored in __cellullar fluid
Extra, intra
Na/K+ ATPase transports…
3 sodium ions outside the cell, and 2 potassium ions into the cell
Most common cause of hyponatremia is from…
….H2O gain
Isotonic hyponatremia definition
Also knwon as factitous or pseudohyponatremia, this occurs when sodium levels are normal but measured low due to fats and proteins in the blood
Hypertonic hyponatremia definition
Increased solutes in plasma such as glucose or mannitol redistribute the volume of fluid from intra to extracellular space causing dilution resulting in hyponatremia
Hypotonic hyponatremia definition
Occurs when excess of H2O exceeds Na+ conc.
Euvolemic hyponatremia conundrum and how to evidence increased body H2O
-Occurs when patients have pure H2O excess extracellularly but not intravascularly, and appear euvolemic with the only evidence of increased total H2O is a lowered BUN
Central pontine myelinolysis definition
Demyelination that occurs resulting in irreversible neurological defect after treatment of Na+ over 10 MEQ in 24 hrs or 18MEQ in 48 hrs
When treating a patient with hypernatremia need to give a __tonic solution first because…
isotonic, because it prevents cells from expanding too quickly and bursting by introducing fluid back in slowly until it can equally distribute and stabilize the BP
Glucose and insulin administration can help drive ___ back into cells
K+
European black licorcie has the same effect in the body as…
…aldosterone
Bartter syndrome definition
Rare inherited defect in thick ascending limb of loop of henle characterized by low K+ levels and high pH
Correction for hypokalemia if <40k, what about if >40kg
.25 MEQ/kg/hr
10 MEQ/kg/2hrs
Symptoms of hyperkalemia (3)
- weakness
- flaccid paralysis
- hyperactive DTR’s
An EKG with a flat “T” wave and shortened QRS complex is a sign of… What about with peaked T waves and widened QRS complex
Hypokalemia, hyperkalemia
Calculation for fluid replacement therapy maintenance
- first 10 kg 100ml/kg/day
- 2nd 10 kg 50ml/kg/day
- remaining 20ml/kg/day
With a functioning kidney, an individual should intake approx ___L per day and urinate out that same amount
1.5-2L
Fluid replacement therapy’s formula is chosen to ensure good urine output in hospitalized patient, what is the minimal output to ensure good renal perfusion?
720mL/day
Almost ___ L is lost each day to skin evaporation, respiration, and GI tract
1
IV fluid in mL/hr is summation of 5 items
- baseline maintenance
- deficit
- ongoing losses
- 3rd spacing
- compensatory
Calculation for fluid replacement therapy deficit
Acute loss give 1/2 deficit over first 8 hours, 1/4 deficit over next 8 hrs
Chronic loss give 1/2 deficit over 24 hours
BUN will have increased concentration if…
…there is decreased blood flow to kidney
Azotemia definition
Presence of elevated BUN
Uremia definition
Advancing azotemia with increased BUN and Cr, indicates renal failure
Vasopressor definition
The name of the local paracrine factor secreted by macula densa cells to communicate with juxtaglomerular cells thru mesangial cells indicating the JG cells need to release renin
When blood pressure is too high, macula densa cells can secrete ___ that inhibit ___ release from JG cells
Paracrine factors, renin
Nephrotic syndrome results from injury to the ___ (cells) while nephritic syndrome is ____ based, involving ____
Podoctyes, inflammation, blood in the urine
Most nephrotic syndromes have a ___basis
Immunologic
Does antibiotic treatment prevent glomerular disease in post strep glomerulonephritis?
Nope, immune mediated doesn’t have to do when treatment was sought after
A strep infection often goes on to cause either ____ or ____ but rarely both
rheumatic fever, acute glomerulonephritis
Treatment of post strep glomerulonephritis (3)
- supportive diuretics
- control hypertension
- dialysis in extreme cases
Prognosis of post strep glomerulonephritis
Very good, see recovery often within 2 months
Goodpasture’s syndrome definition
A type II hypersensitivity invoolving antibody formation against the glomerular basement membrane, rapidly progressive to renal failure
Most common glomerular cause of hematuria
IgA nephropathy/berger’s disease
IgA nephropathy/berger’s disease definition
Attacks of hematuria following nonspecific illness, exercise, or immunization that is benign and result of excessive IgA antigen complex formation
IgA nephropathy/berger’s disease treatment (2)
- supportive care of hypertension
- steroids if progressive to suppress immune response
Rapidly progressive glomerulonephritis (RPGN) definition
Acute glomerulonephritis marked by rapid loss of renal function >50% over a period of 3 months with renal crescents upon biopsy
75-80% of all nephrotic syndromes in kids and 20% in adults is from…
…minimal change disease
Minimal change disease definition
Nondamaging cause of proteinuria leading to nephrotic syndrome, sometimes seen with allergies, malignancies, or certain drugs
Minimal change disease presents as ___onset of nephrotic syndrome
abrupt
Focal segmental glmoerulosclerosis definition
Scarring of some of the glomeruli of the kidney either idiopathic or due to infection, or drug, or a disease
Focal segmental glmoerulosclerosis prognosis
Poor
Most common primary cause of nephrotic syndrome in adults is…
…membranous glomerular disease
Captopril drug class
ACEI
Causes of membranous glomerular disease are typically ___ and include (3), how does it present (3)?
Autoimmune
- nephrotic syndrome
- cancers
- Hep B
Presents with proteinuria and sometimes hematuria or malaise
P
Membranoproliferative glomerulonephritis (MPGN) results in ___ GFR and ____ mesangial cellularity
decreased, increased
Mostcommon cause of end stage renal disease in US
Diabetes
Kimmelsteil Wilson lesion definition
Hallmark change seen in kidney from mesangial matrix expansion, nodular appearance indicative of glomerulonephropathy from diabetes
Cortical nephrons focus on controlling ____ while medullary ones are focused on ____
BP, reabsorption
Acute interstitial nephritis definition, what 3 things does it lack compared to glomerular disease?
Acute decline in renal function due to inflammation of the nephron, lacks HTN, proteinuria, or edema unlike glomerulonephritis
Acute interstitial nephritis triad
- fever
- skin rash
- peripheral eosinophilia
Acute interstitial nephritis can present as TINU syndrome, which is…
…tubulointerstitial nephritis and uveitis syndrome
Acute interstitial nephritis urine appears…
…coke colored
Causes of acute interstitial nephritis (4)
- antibiotis
- NSAIDS
- systemic infections
- autoimmune
Chronic tubulointerstitial nephropathy definition, what does it frequently present with?
Disease of the nephron tubule, frequently presents with hyperkalemia
Sequelae of chronic tubulointerstitial nephropathy
Fanconi syndrome
Fanconi syndrome definition
dysfunction of proximal tubules of kidney resulting in renal glycosuria, water and bicarb loss, and metabolic acidosis
