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Clin med A 2 > Renal 1 > Flashcards

Renal 1 Flashcards

1
Q

what are the 9 major renal function

A
  1. excretion of metabolic waste products
  2. regulation of water and elctrolyte balance
  3. regulation of extracellular fluid volume
  4. regulation of plasma osmolality
  5. Regulation of RBC production (EPO)
  6. regulation of vascular resistance (renin)
  7. regulation of acid base balance
  8. regulation of vit D and bone mineral balance
  9. gluconeogenesis
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2
Q

what are the waste products excreted by the kidney

A

proteins - urea
nucleic acid - uric acid
muscle creatine - creatinine
hemoglobin - urobillin

also hormone metabolites, drugs and toxins

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3
Q

how does kidneys regulate vascular resistance

A

↓ renal BP causes juxtaglomerular cells in afferent arteriole to release renin
Renin → peripheral vasoconstriction → ↑ BP

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4
Q

describe a healthy kidney

A
  1. renal metabolism is equal to general BMR
  2. lower oxygen in body as a whole is correlates with lower oxygen in renal tissues
  3. low oxygen triggers EPO prodction by interstitial cells = inceased RBC production
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5
Q

describe a diseased kidney

A
  1. renal metabolism is LOWER than general BMR
  2. hypoxia in the body as a whole does not necessarily equate to renal hypoxia
  3. Slower local oxygen consumption of diseased renal tissue means oxygen levels do not drop at the same rate as the rest of the body and erythropoietin production is blunted
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6
Q

how do the kidneys regulate vitamin D and bone mineral balance

A

because active Vit D (calcitriol) is made in the kidneys

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7
Q

when are the kidneys used in gluconeogenesis

A

most occurs in the liver but kidneys contribute especially during FASTING

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8
Q

Describe the location of the kidneys

A

Just below rib cage, retroperitoneal, near posterior abdominal wall

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9
Q

what supplies the kidneys

A

Serviced by renal artery and vein, renal pelvis, nerves

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10
Q

what is the hilum

A

Curved side of kidney

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11
Q

what is the renal medulla

A

the collective terminology for the renal pyramids

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12
Q

what connects to the papillae

A

minor calyces

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13
Q

what surrounds the medulla

A

renal cortex, which is also covered by fibrous tissue capsule

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14
Q

what is the interstitium

A

fluid and cells that secrete ECM. some cells here also secrete EPO!

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15
Q

what are the working tissue masses of the kidneys

A

the tubules (nephrons and collecting tubules) and blood vessels

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16
Q

How are working tissues arranged
in the cortex

A

tubules and blood vessels are intertwined randomly

Cortex also contains scattered spherical renal corpuscles

looks like “speghetti and meatballs”

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17
Q

How are working tissues arranged in the medulla

A

tubules and blood vessels are arranged parallel

think medulla has two L’s and they are parrallel

looks like “bundles of pencils”

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18
Q

what is the term for the beginning of the nephron and what does it consist of

A

renal corpuscle

consists of glomerulus + glomerular capsule

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19
Q

describe the juxtamedullary nephron

A
  1. Loop of Henle is much longer, goes into the inner medulla
  2. Glomerulus located close to the boundary of the cortex and medulla
  3. Major role in urine concentration
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20
Q

describe the cortical nephron

A
  1. Relatively shorter
  2. Loop of Henle only goes into outer medulla
  3. Majority of nephron remains in the cortex
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21
Q

what is bowmans capsule

A

surrounds the glomerulus and is part of the renal corpuscle

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22
Q

what is the renal corpuscle

A

The glomerulus + the bowmans capsule!

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23
Q

what is the function of the afferent arteriole

A

carries blood into the corpuscle

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24
Q

describe the glomerulus

A

interconnected capillary loops where plasma is filtered.

fluids and substances to be extreted exit the capillaries and enter bowmans space.

capillaries are surrounded by podocytes

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25
Q

what are the functions of podocytes

A

surround the cappillaries in the glomerulus and function to:
1. remove material trapped in wall of capillaries
2. contract capillaries if needed.

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26
Q

what is the function of efferent arterioleis

A

carry blood OUT of the corpuscle

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27
Q

what are the two parts of the proximal tubule and where are they found

A

proximal convoluted tubule - found in cortex

proximal straight tubule - found decending into medulla

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28
Q

what are the four segments (in order) of the renal tubules

A
  1. proximal tubule
  2. loop of henle
  3. distal tubule
  4. collecting duct
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29
Q

what are the three parts of the loop of henle and their locations

A

descending limb - all begin at the same level, penetrate to different depths

Thin ascending limb - absent in “shallow” nephron loops

Thick ascending limb - distal portion - all begin at same level

All loops return to the same capsule they started from - cells in thick ascending limb closest to the capsule are specialized cells known as the macula densa

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30
Q

what is the other name for the distal tubule

A

distal convoluted tubule

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31
Q

what is the function of the collecting duct

A

joins tubules from nephrons

Collecting ducts merge to form successively larger ducts that eventually empty into a minor calyx

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32
Q

what is the etiology of horseshoe kidney (renal fusion)

A

thought to occur during
fetal organogenesis

2x more common in men

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33
Q

what is the pathophysiology of horseshoe kidney

A
  • abnormal blood supply
  • abnormal course of ureters
  • often located lower than normal kidneys therefore NOT protected by ribs
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34
Q

What are the Symptoms of horseshoe kidney

A
  • 1/3 asymptomatic
  • UTI (MC complaint in children)
  • abdominal pain/nausea
  • increased incidence of complication
  • other GU abnormalities/malformations
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35
Q

what are the complications of horseshoe kidney

A
  • ureteropelvic junction obstruction (MC)
  • renal lithiasis
  • severe/upper UTI
  • Vesicoureteral reflux
  • Increased incidence of renal tumors/cancer
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36
Q

Diagnostic studies for horseshoe kidney

A
  • CT with Intravenous Pyelogram
    (May also do abdominal/pelvic CT or US)
  • Urinalysis/Urine Culture often performed
  • Renal function labs
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37
Q

What is treatment for horseshoe kidney

A
  • Medical - to manage disorders that
    could predispose to complications
  • Surgical - to manage complications
    as they arise
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38
Q

describe the contents of bowmans capsule

A

contains glomerular filtrate which is like plasma but with no proteins present.

this is the location which GFR is obtained

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39
Q

what is GFR?

A

Volume of filtrate formed per unit of time (usually mL/min)

  • Healthy young adult male - 180 L/d (125 mL/min)
  • Entire plasma volume is filtered by the kidneys approx. 60 times/day
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40
Q

what is reabsorbed in the proximal tubule

A
  • ~60% of NaCl and H2O
  • ~90% of filtered HCO3-
  • Almost all glucose, amino acids
  • Most K, PO4, Ca, Mg, urea, uric acid
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41
Q

what is produced/created in the proximal tubule

A

Ammonia! major site of production

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42
Q

what is secreted by the proximal tubule

A
  • organic anions (e.g., urate)
  • organic cations (e.g., creatinine, dopamine, Ach, epinephrine, histamine)
  • Urea
  • Ammonia
  • Protein-bound drugs, chemo rx, toxins
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43
Q

what is the function of the descending loop of henle

A
  • Highly water-permeable
  • Reabsorbs ~15% H2O
44
Q

what is the function of the
thin ascending loop of henle

A

Impermeable to water and ions except Na+ and Cl-, which are reabsorbed by diffusion

45
Q

what is the function of the thick ascending loop of henle

A
  • Very low water permeability
  • Reabsorbs…
    -NaCl via Na+/K+/2 Cl- pump
    -Some Calcium and Magnesium
    -May HCO3- reabsorption
  • May see secretion of urea
46
Q

What is the Target for loop diuretics

A

the thick ascending loop of henle (na/K/2 Cl pump)

47
Q

what is reabsorbed by the distal tubule

A
  • ~5% of NaCl
  • little H2O (low permeability)
  • May reabsorb urea

also regulates calcium and pH

48
Q

how does the distal tubule regulate pH

A

by either of the following:
* reabsorbing HCO3- and secreting H+
* reabsorbing H+ and secreting HCO3-

49
Q

what is secreted by the distal tubule

A

K+

50
Q

what is the target site for thiazide diuretics

A

Distal tubule

51
Q

what are the two types of cells in the cortical collecting duct

A

principal cells
intercalated cells

52
Q

what is the function of principal cells

A
  • reabsorb NaCl and H2O
  • secrete K+
  • Site of action for aldosterone, eplerenone, and other K+-sparing diuretics
53
Q

what is the function of intercalated cells

A

mediate HCO3- and H+ secretion and reabsorption

54
Q

what is the final site of urine modification

A

medullary collecting duct

55
Q

what is the function of the medullary collecting duct

A
  • Final modification of urine
  • Reabsorb NaCl, water and urea
  • Secretes ammonia and H+
  • Secretes or reabsorbs K+
56
Q

what can cause acute nephron damage ( sudden loss of renal function )

A
  • Hypotension (blood loss, septic shock, dehydration, heart failure)
  • Obstruction of urine flow (BPH, renal stone, tumor)
  • Substances (medications, toxins, myoglobin)
57
Q

what can cause chronic nephron damage (slow, gradual loss of renal function)

A

Diabetes Mellitus
HTN
Autoimmune diseases
Infection/Inflammation
Polycystic disease
Nephrotoxic Substances

58
Q

why is nephron damage so detrimental

A

because nephrons can not be regenerated after loss!

59
Q

what is compensatory renal hypertrophy

A

increased size of each cell in nephron

60
Q

when is compensatory renal hypertrophy seen

A

Seen in situations of ongoing hyperfiltration
* Pts born with one kidney
* Loss or donation of a kidney
* Pregnancy

this produces no ill consequences and can aid kidneys in achieving 80% of prior function

61
Q

what does end stage renal disease result from

A
  • Resection of significant amount of renal mass (~80%)
  • Destruction of a significant amount of nephrons
62
Q

what occurs when nephrons cannot compensate?

A

maladaptive deterioration

63
Q

describe the process of renal disease progression

A

progressive nephron loss after severe or persistent disease

  • Persistent glomerular HTN →
  • Damaged glomeruli →
  • Protein leakage and proteinuria →
  • Inflammatory immune response →
  • Renal tissue responds to inflammation with fibroblasts →
  • Fibroblasts lay matrix that disrupts capillaries and tubules →
  • Matrix becomes an acellular scar
64
Q

what is the GFR for people with early CKD

A

60-99 for 3+ months with kidney damage markers is indicative of early CKD

65
Q

what is the GFR for people with CKD

A

GFR<60 for 3+ months

66
Q

will people with kidney disease always have decreased GFR. Why or why not

A

NO! can have normal or increased GFR due to:

  • hyperfiltration at the glomerulus
  • disease affecting various kidney areas

beware that GFR may not mean what you think!
Stable GFR ≠ stable disease
Improved GFR ≠ improved disease
Normal GFR ≠ no kidney disease

67
Q

what are the methods of estimating GFR

A

using a freely filtered substance that is not secreted, reabsorbed or changed along the tubule (BUN, Cr, cystatin C)

or can use:
24 hr creatinine clearance (CrCl)
estimation equations

68
Q

how does body surface area affect GFR estimation

A

kidney function is proportional to kidney size which is proportional to BSA

smaller body = lower metabolic demands = less muscle mass = smaller kidney size

69
Q

how does age affect GFR estimation

A

GFR declines with age even in patients w no hx of CKD

declining GFR is an independent risk factor for adverse health outcomes

70
Q

what are the four factors affecting GFR estimation

A

Body surface area
age
gender
race

71
Q

how does gender affect GFR estimation

A

males tend to have higher muscle mass and creatinine generation which decreases GFR

72
Q

how does race affect GFR estimation

A

african americans tend to have higher muscle mass and creatinine generations, some GFR calculators take this into account

73
Q

how is creatine obtained in the body

A

50% manufactured by the liver
50% absorbed from food (meat)

74
Q

how is creatine used and metabolized

A
  • taken up by high metabolism tissues such as skeletal muscle and brian.
  • metabolized by creatine kinase into creatine phosphate which can be used as fuel for ATP production
  • creatinine is the waste product of creatine
75
Q

how does creatinine affect GFR

A

increased creatinine = decreased GFR
decreased creatinine = increased GFR

76
Q

what factors can increase serum creatinine

A
  • higher muscle mass
  • increased meat intake
  • increased creatine supplements
77
Q

what factors can decrease creatinine

A

vegetarian
antibiotics or cimetidine
liver disease

78
Q

how does creatinine respond to early v late CKD

A
  • Early CKD - creatinine secretion is enhanced, blunting the expected rise in serum Cr
  • Late CKD - extrarenal creatinine elimination increases, blunting expected rise in Cr
79
Q

How does creatinine clearance estimate renal function compared to true GFR

A

estimates a higher renal function than true GFR.

this means creatinine clearance estimates GFR at the upper limit for what the true GFR may be

80
Q

what is required when using creatinine clearance for GFR

A

24 hours urine measurement
check this

81
Q

how do you obtain a urine sample for 24 hr CrCl

A

void intial urine after waking up and then collect ALL urine for the next 24 hours.

finish with collecting the first urine of the next morning within 10 min of 24 hour mark

82
Q

what are the limitations of 24 hour urine CrCl

A
  • incomplete urine collection
  • cumbersome = poor compliance
  • increased ceratinine secretion as GFR falls (idk what this means)
  • overestimation of GFR
83
Q

what is urea

A

a waste product of protein created by the liver

84
Q

where is urea obsorbed

A

30-70% reabsorbed in the renal tubules

85
Q

how does volume depletion affect urea reabsorption in tubules

A
  • Reabsorption decreased in volume replete pts
  • Reabsorption increased in volume deplete pts

dont reallu understand this but ok

86
Q

what is the normal BUN:Cr ratio

A

10:1 to 20:1

87
Q

how does volume depletion effect BUN:Cr

A

ratio may increase (20:1 or higher)

88
Q

what factors could cause an increased BUN

A
  • Dehydration
  • Catabolic (cell breakdown) states such as GI bleed, cell lysis, corticosteroids
  • Increased dietary protein
  • Decreased renal perfusion such as during HF, RAS
  • Tetracycline
89
Q

what causes decreased BUN

A
  • Liver disease
  • Malnutrition
  • Sickle cell anemia
  • SIADH
90
Q

how does BUN correlate with GFR

A

they are inversely correlated but BUN can change independently of GFR:

Rate of urea production is not constant
40-50% of filtered urea is passively reabsorbed
increased in volume depletion
BUN rises out of proportion to change in GFR and Cr

91
Q

what is a better calculation of GFR? BUN or Cr

A

Cr because BUN can change independently of GFR.

92
Q

when is BUN most used?

A

CKD patients

93
Q

what is cystatin C

A

a protein produced at a fairly steady rate by all nucleated cells in the body

94
Q

pros and cons of Cystatin C

A

Pros
* Less directly affected by muscle mass and metabolism than creatinine
* Not as impacted by age, sex, gender, or race as creatinine
* varies less than other markers

Cons:
* expensive

95
Q

when is Cystatin C mostly used for GFR

A

when creatinine is at high risk for not being accurate:
* elderly
* body builders
* acutely ill patients (esp w muscle mass change)

96
Q

what is the cockcrault-Gault equation

A

estimation of CrCl based on serum Cr in a patient with stable Cr

accounts for advancing age and weight increase

97
Q

what are the limitations to the cockrault-Gault equation

A
  • it was developed when obesity was less common and therefore it does not account for BSA
  • it is highly dependent on serum Cr
98
Q

what is the conclusion on reliability of the cockrault-Gault equation

A

it overestimates CrCl and is considered to be low accuracy

99
Q

what is the actual equation of the Cockcrault-Dault equation

A

Idk if we actually need to know this so if you know plz text me lmao

100
Q

What is the MDRD study equation

A

an equation that estimates GFR that is adjusted for body surface area. It is based on data from adult patients

101
Q

what is the conclusion on reliability of the MDRD equation

A

more accurate than cockroft-Gault formula but it has not been studied in different back grounds (elderly, obese, diverse ethnic/racial backgrounds)

102
Q

what is the actual equation of the MDRD study equation

A

dont need to know this so 5 it

103
Q

What is the CKD-EPI study

A

a more accurate estimation of GFR than MDRD or cockrault-gault equation in patients with normal or mildly reduced GFR.

104
Q

what are the order of the equations in order of most to least reliability

A
  1. CKD-EPI study
  2. MDRD
  3. Cockrault-Gault equation
105
Q

what is the preferred equation to use for GFR in the US

A

CKD-EPI 2021

Clin med A 2 (30 decks)

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