Renal

Question 1

What are the Hypertension Mechanisms

Answer 1

Peripheral Resistance: Narrowed arteries increase blood flow resistance, requiring the heart to pump harder.

Excess Sodium: High salt intake leads to fluid retention and increased blood volume, elevating pressure in arteries.

RAAS Activation: Renin release triggers angiotensin production, constricting vessels and promoting fluid retention.

Sympathetic Nervous System: Stress activates this system, raising heart rate and constricting vessels.

Endothelial Dysfunction: Damaged vessel lining disrupts blood vessel tone regulation.

Genetics: Family history can predispose individuals to hypertension.

Obesity: Adipose tissue releases factors that disrupt blood pressure regulation.

Insulin Resistance: Diabetes damages vessels, impairing their flexibility.

Lifestyle Factors: Poor diet, inactivity, alcohol, and smoking contribute to hypertension.

Age: Blood vessels become less flexible with age, contributing to elevated blood pressure.

Hormonal Changes: Pregnancy or medical conditions can raise blood pressure temporarily or chronically.

Question 2

how can reduced nitric oxide levels can induce hypertension

Answer 2

Nitric Oxide (NO): Vasodilator gas released by blood vessels, relaxing them.

Vasodilation: NO widens vessels, reducing resistance and blood pressure.

Endothelial Dysfunction: Damage to vessel lining reduces NO production.

Constricted Arteries: Reduced NO leads to vessels staying narrow.

Increased Resistance: Constricted vessels raise blood pressure due to greater effort required from the heart.

Hypertension: Chronic elevated pressure from NO deficiency contributes to hypertension.

Question 3

What is hypertension

Answer 3

• Failure of blood pressure (BP) due to control/compensatory mechanisms
• Consistently elevated: Systolic BP ≥ 140 mmHg & Diastolic BP ≥ 90 mmHg

Question 4

What is primary hypertension

Answer 4

• Primary Hypertension
  o Underlying cause is unknown
  o 90% of cases
  o Known as Essential or Idiopathic Hypertension

Question 5

What is secondary hypertension

Answer 5

o A definite cause can be established
o 10% of cases
o Hypertension that occurs secondary to another known primary problem

Question 6

What is resistant hypertension

Answer 6

• When patients fail to achieve optimum blood pressure targets despite being on 4-5 different anti-hypertensive drugs
• Obesity is a major risk factor for resistant hypertension

Question 7

What does obesity lead to

Answer 7

o Atherogenic dyslipidemia
o Pro-thrombotic state
o Insulin resistance
o Hypertension
o Endothelial dysfunction

Question 8

What is Obesity induced hypertension

Answer 8

• Hypertension is a major risk factor for a number of cardiovascular diseases
• 60-70% of cases of hypertension arise from obesity
  o The precise mechanisms which link obesity with hypertension remain to be determined

Question 9

What are the functions of the kidney

Answer 9

• Regulation of water & electrolyte volume & osmolarity
  o Sodium, chloride, potassium, phosphate, magnesium
• Regulation of acid-base balance
  o Hydrogen ions (pH)
• Excretion of metabolic waste products and foreign chemicals e.g., nitrogen
• Removal of foreign chemicals from blood
  o Drugs, pesticides and food additives
• Secretion of hormones
  o Renin = controls the formation of angiotensin
  o Erythropoietin = stimulates red blood cell production
  o 1,25-dihydroxy vitamin D3
• Reduced nitric oxide levels lead to impaired kidney function and high blood pressure (hypertension)

Question 10

What are the Cardiorenal Syndrome (CRS) statistics

Answer 10

• Heart failure = 1.8% Australian population
• 50% of heart failure develop renal failure

Question 11

What happens in Heart failure with preserved ejection fraction (diastolic heart failure)

Answer 11

heart struggles to fill (walls of heart are thickened and stiff)

Question 12

What happens in Heart failure with reduced ejection fraction (systolic heart failure)

Answer 12

Heart struggles to pump (walls of heart are thin and dilated)

Question 13

What is stage 5 chronic kidney disease

Answer 13

End stage renal disease = eGFR less than 15

Question 14

What is chronic kidney disease

Answer 14

When kidneys are damaged or diseased they don’t make enough EPO causing the bone marrow to make fewer red blood cells resulting in anemia

Question 15

How is chronic kidney disease diagnosed

Answer 15

CKD is diagnosed by reduced eGFR, elevated blood urea nitrogen and reduced hemoglobin levels

Question 16

How does reduced nitric oxide impact kidney function

Answer 16

• Reduced renal perfusion
• Impair sodium and water reabsorption
• Reduced glomerular filtration rate
• Impair tubuleglomerular feedback mechanism
• Impair myogenic response
• Enhanced renal vasoconstrictor responses to renal sympathetic nerve activity, thereby leading to renal ischemia

Question 17

What is the RAAS (functions, stages, effects)

Answer 17

Function: Regulates blood pressure and fluid balance.

Initiation: Low blood pressure or sodium levels stimulate renin release.

Angiotensin: Renin converts angiotensinogen to angiotensin I.

Angiotensin-Converting Enzyme (ACE): Converts angiotensin I to angiotensin II.

Angiotensin II: Potent vasoconstrictor, raises blood pressure.

Aldosterone: Angiotensin II stimulates adrenal glands to release aldosterone.

Aldosterone’s Role: Increases sodium reabsorption in kidneys, promoting water retention.

Effects: Vasoconstriction, fluid retention, and increased blood pressure.

Question 18

What are the actions of angiotensin 2

Answer 18

-Potent vasoconstrictor – nitric oxide counteracts this effect

-Activates sodium reabsorption

-Stimulates aldosterone production

Question 19

What is the key driver of cardiorenal syndrome

Answer 19

Fibrosis

Question 20

How does fibrosis occur and lead to cardiorenal syndrome

Answer 20

• Renin angiotensin aldosterone system (RAAS) activation increases oxidative stress
• Oxidative stress reduces nitric oxide
• Reduced nitric oxide levels can activate pro-fibrotic pathways, this includes increasing the expressing of plasminogen activator inhibitor-1 (PAI-1). PAI-1 contributes to fibrosis in the heart and the kidney
• Fibrosis leads to impaired function of the heart and the kidney which contributes to cardiorenal syndrome

Question 21

What is oxidative stress

Answer 21

• Oxidation exceeds reduction = oxidative stress
• Oxidative stress = DNA damage, aging, cell death, multiple pathogeneses
• Oxidative stress is the imbalance between generation of oxidants (ROS and/or RNS) and Antioxidant defenses

Question 22

How are Inflammatory and phagocytic cells are the main cellular sources of ROS

Answer 22

Lysosomes – Organelles that act as a roving garbage cell. However they can rupture and cause damage to mitochondria and oxidative stress via the released lysosomal enzymes

Question 23

What are NADPH Oxidases

Answer 23

The NOX1 (NADPH oxidase 1) and other NADPH oxidases are the major sources of ROS in the artery wall in disease such as hypertension, diabetes and ageing

Question 24

What is diabetes mellitus

Answer 24

Group of metabolic disorders with common underlying feature of hyperglycemia
Defects in insulin action or insulin secretion
Associated with end-stage kidney disease

Question 25

How does oxidative stress induce insulin resistance

Answer 25

• Oxidative stress has the ability to lower insulin sensitivity and injure the insulin producing beta cells within the pancreas
• Oxidative stress modifies the signaling pathways within a cell causing insulin resistance
• Oxidative stress can destroy so many beta cells that the patient becomes insulin dependent

Question 26

What is the definition of Acute Kidney Injury

Answer 26

• Abrupt deterioration in kidney function (kidney failure)
• Increase in serum biomarkers (creatinine, reduced urine output and blood urea nitrogen)
• Decreased glomerular filtration rate
• AKI is the presence of any of the following
  1. Increase in serum creatinine by 0.3 mg/dl or more within 48 hours
  2. Increase in serum creatinine to 1.5 time or more of baseline measured within the prior seven days
  3. Urine volume less than 0.5 ml/kg/h for at least 6 hours

Question 27

What are pre-renal causes of Acute Kidney Injury

Answer 27

• Hypovolemia – hemorrhage, serve burns, and gastrointestinal fluid loss (e.g., diarrhea and vomiting)
• Hypotension from decreased cardiac output – cardiogenic shock, massive pulmonary embolism, acute coronary syndrome

Question 28

What are Intrinsic causes of acute kidney injury

Answer 28

• Acute tubular necrosis – caused by ischemia from prolonged prerenal injury
• Acute interstitial nephritis – drugs such as beta-lactam antibiotics, penicillin and NSAIDs
• Glomerulonephritis

Question 29

What are the vascular causes of decreased Glomerular filtration rate

Answer 29

• Endothelial dysfunction and death
• Increased vasoconstriction
• Decreased vasoconstriction
• Increased adhesion of acute inflammatory cells

Question 30

What are the Tubular causes of decreased Glomerular filtration rate

Answer 30

• Cytoskeletal injury
• Necrosis/apoptosis/sub-lethal injury
• Desquamation (loss of attachment) of cells
• Obstruction

Question 31

How is chronic kidney disease defined

Answer 31

• Evidence of kidney damage (such as proteinuria)
• Reduction in glomerular filtration rate
• Persists for more than three months

Question 32

What are the structure indicators for chronic kidney disease progression

Answer 32

• Tubulointerstitial fibrosis
• Vessel rarefaction/loss
• Tubular atrophy

Question 33

What are the outcomes of chronic kidney disease

Answer 33

• Blood is not cleansed – toxic contents build up
• Fluid balance is no longer automatic
• Hypertension is common in people with kidney failure (cause and complication of kidney failure)
• Kidneys fail to produce adequate erythropoietin (causing amenia due to lack of healthy red blood cells)
• Calcium and phosphate imbalance, renal bone disease