Renal Flashcards
What is the main physiological function of the kidneys?
Maintenance of the composition and volume of extracellular fluid
What is extracellular fluid?
Fluid outside cells, but on the serosal side of epithelial tissues
So, bladder urine, GI tract fluid, and lung fluid are not ECF
How much extracelular fluid do we have? What are the 2 main compartments?
15 L
12L interstitial fluid
3 L Plasma
How do we maintain homeostasis of stuff in the extracellular fluid?
Through urine production
What are the 2 capillary beds of the kidneys?
Glomerular
Peritubular
What is glomerular filtration?
Filtration of plasma into the tubule.
Allows water and solutes in, but retains larger colloids
What is the filtration fraction? What is its normal value?
Amount of renal plasma flow filtered at the glomerulus.
20% of renal blood flow
What induces the kidneys to secrete renin? (3)
Activation of renal beta-sympathetic nerves
Stimulation of renal baroreceptors by decreased arteriolar pressure
Activation of macula densa chemoreceptor by reduced delivery of NaCl to the distal rubule
Which cells in the kidney secrete renin? Where are they? What structure are they part of?
Granular cells, in the afferent arteriole going to the glomerulus
Juxtaglomerular apparatus
The molecular sieving process of the glomerulus is also called _______________
Ultrafiltration
What is filterability a function of?
Molecular size
What are the 3 filters of the glomerulus?
Fenestrated epithelium
Basal lamina
Podocytes
What is the charge of the basal lamina?
Negative, so negatively charged things don’t get through
Mathematical description for GFR
GFR = dP/R = KdP = K(Pgc-Pt-Pigc)
Pressures of glomerular capillary, tubule, colloid osmotic pressure)
What are 2 forces that oppose glomerular filtration?
Tubule diameter -> backpressure = Pt
Colloid osmotic force
What is the net filtration pressure?
Sum of glomerular capillary, tubule, colloid osmotic pressures
What do mesangial cells do? (3)
Secrete matrix continuous with basal lamina
Do some macrophage-like things (make cytokines, etc)
Unclear role in contraction of glomerular capillary loops
Is glomerular capillary pressure dependent on mean arterial pressure?
No. It is very tightly autoregulated
What is the glomerular response to chronic hypotension?
Both the afferent and efferent arterioles constrict
This decreases flow through the glomerulus (so it can go to other organs) but sort of maintains Pgc (glomerular capillary pressure)
3 baroreceptors that affect glomerular arterioles
Baroreceptors in main arteries -> sympathetic response
External baroreceptors -> antiogensin II constricts
Intrarenal baroreceptors -> RAAS
Where are renal interstitial cells located? What do they do?
Located in kidney medulla between renal pyramids
Make renal prostaglandins
When are renal prostaglandins produced? What do they do?
Secreted in response to angiotensin II
Dilate renal arterioles -> maintain adequate renal blood flow, maintain GFR. This blunts effects of hypovolemic mechanisms so the kidney doesn’t get ischemic
Compare autoregulation and hypovolemic response:
Responds to Purpose Arterioles involved Mechanism of arteriolar changes Location of mechanism
mrr
What do the minor calyxes do? Major calyx?
Drain renal pyramids
Drain minor calyxes
What do the medullary pyramids contain?
Nephrons and collecting ducts
What is the path of the renal arteries to veins?
Renal artery -> anterior and posterior segments -> interlobar (between medullary pyramids) -> arcuate arteries (parallel to outer capsule) -> interlobular -> afferent arterioles -> glomerular capillary -> efferent arterioles -> vasa recta ? -> peritubular capillary -> interlobular veins -> arcuate veins -> interlobar veins -> renal vein
What part of the kidney are renal corpuscles located in?
Cortex
What part of the kidney are renal tubules in?
Medulla
What kind of epithelium is in the proximal tubule?
Cuboidal with brush border
What does the proximal tubule transport?
Na/K ATPase for pumping sodium out of the basolateral side
What is the epithelium like in the thin loop of Henle?
Simple squamous
What is the epithelium like in the thick loop of Henle?
Cuboidal
What is the epithelium like in the distal tubule?
Cuboidal
Where do aldosterone and antidiuretic hormone act in the kidney?
Distal tubule
What two hormones act on the distal tubule?
Aldosterone
Antidiuretic hormone
The distal convoluted tubule is physically connected to the region near the vascular pole through the _______
Macula densa
Where are the Lacis cells located?
Between macula densa and mesangial cells
What is another name for antidiuretic hormone?
Vasopressin
What is the major osmotic substance in the ECF?
Sodium
Where are the osmoreceptors?
Supraoptic nucleus of the hypothalamus
What makes antidiuretic hormone?
Hypothalamus (specifically, the supraoptic nucleus)
OR maybe the pituitary
Mental states with increased risk of suicide
Hopelessness
Helplessness
Impulsivity
Are all patients who kill themselves depressed?
No
How do you protect against suicide in schizophrenia?
Clozapine
What CSF substance is associated with an increased risk of violence and suicide?
5-HIAA (hydroxyindoleacetic acid)
What are 2 groups of people who are at high risk of completing suicide?
Single male who lives alone
Chronic physical illness
7 psychiatric illnesses that predispose to suicide
Depression Schizophrenia Bipolar mood disorder Drug or alcohol problems Cognitive disorder Anorexia nervosa Personality disorder with axis I co-morbidity
When is risk of suicide highest in renal disease? What does this mean?
First 3 months of dialysis
Suicide is prompted by failure to cope with stress rather than declining health status
5 errors made in the evalulation of psychiatric patients
Not corroborating story with family/friends
Not reviewing old records
Not seeking consultation
Avoiding specific questions about guns, plans, fantasies, etc
Ignoring risk enhancing factors
How much fluid is in the intracellular compartment? What are the 2 parts?
27L
Noncirciulating cell volume = 24L
Blood cells = 3L
What are the insensible water losses?
Respiration, skin
The ones you can’t sense I guess
How much of the cardiac output do kidneys recieve?
25%
Why do filtration and reabsorption rates»_space; excetion rates?
Rapid removal of waste products
Precise and rapid volume/composition control of ECF
What important calcium-related substance does the renal system make?
Calcitriol
What is the rate-limiting step of the RAAS?
Renin
What happens to net filtration pressure as we move along the tubule?
It decreases and eventually reaches equilibrium
This is because Pi gc increases and Pgc-Pt decreases
What 2 things make up K, the resistance term in GFR = dP*K?
Hydraulic conductivity
Surface area
K = pA
What 2 things determine filtration fraction?
FF = GFR/RPF
RPF = renal plasma fraction
Which arteriole does angiotensin II act on?
Both, but mostly the efferent (away) one
How do NSAIDS affect the kidneys?
They block prostaglandins, vasoconstricting the afferent arteriole
How do ACEIs and ARBs affect the kidneys?
They block angiotensin II, increasing renal blood flow but decreasing GFR
What is the pH of the urine of carnivores and herbivoes?
Carnivores - acidic
Herbivore - alkaline
What are the 2 sides of the epithelial cells in the renal tubules?
Apical - faces lumen
Basolateral - faces serosa (interstitium and capillaries)
What side are microvilli on?
Apical
How many ions/molecules does a facilitated diffusion carrier take?
At least 2 (why not 1?)
What side is the Na/K ATPase on? Which directions does it transport?
Basolateral
3 Na out, 2K in
What are the jobs of the nephron segments?
Proximal convoluted tubule - bulk reabsorption
Loop of Henle - urine dilution
Distal convoluted tubule - tine-tuning Na balance
Collecting duct - fine-tuning K, acid, water ballance
10 things the proximal tubule cell does
Bulk reabsorption of: Na, water, glucose, amino acids, calcium, phosphate, citrate
H+ secretion/HCO3 absorption
Organic anions secretion
Macromolecule absorption
Is the thick ascending limb permeable to water?
No
What 3 things are reabsorbed in the thick ascending limb?
Na (trans-Na/K/2Cl cotransporter and paracellular)
Ca (paracellular)
Mg (paracellular)
What 3 things are reabsorbed in the distal convoluted tubule?
Na (Na/Cl cotransporter)
Ca
Mg
Where do thiazide diuretics act?
Distal convoluted tubule NaCl cotransporter
2 types of cells in the collecting duct
Principal cells Intercalated cells (alpha, beta)
What do principal cells do (3)?
Fine tune Na (ENaC), K (ROMK/Maxi), water (aquaporin) reabsorption in the collecting duct
What do alpha intercalated cells do?
H+ secretion
HCO3- synthesis
K+ absorption
What do beta intercalated cells do?
HCO3- secretion
CL- absorption
What does aldosterone do to the principal cells in the collecting duct?
Increases Na+ transporters so Na+ goes into the blood
What does vasopressin do the collecting duct?
Allows it to be permeable to water via aquaporins
How does tubular function depend on flow?
Higher velocity - less time for interaction with transporters -> less absorption
Reduced flow rate increases absorption
How do receptors for ECF volume work?
Stretch
4 effects ofsympathetic activity on the kidney
Vasoconstriction
Renin release
Decreased RBF/GFR
Increased renal reabsorption of NaCl
Where is aldosterone made?
Adrenal gland
What does vasopressin do?
Induces expression of aquaporins on collecting duct cells so water can escape out of the urine
8 non-osmotic stimuli for vasopressin
Low effective arterial blood volume Endocrine disorder Pain Nausea CNS disorders Pulmonary disorders Drugs Meds
What are the normal values for PO2
PCO2
and HCO3
94 +-8
38 +-2
24 +-2
What defines acute kidney injury?
Rapid reduction in glomerular filtration rate manifested by a rise in plasma creatinine and urea concentration
What state does acute kidney injury result in?
Reduced clearance of nitrogenous waste products
-> azotemia
What are 3 problems that can cause acute kidney injury?
Pre-renal azotemia - decreased GFR from decreased renal plasma flow or renal perfusion pressure
Post-renal azotemia or obstructive nephropathy - decreased GFR due to obstruction of urine flow
Intrinsic renal disease - decreased GFR from direct injury to the kidneys
What is oliguria?
What is anuria?
Decreased urine (
What is the most common cause of an abrupt decrease in GFR in a hospitalized patient?
Prerenal azotemia
What are 2 hypervolemic states that can cause pre-renal azotemia?
Congestive heart failure
Cirrhosis
These diseases are characterzed by low effective arterial blood volume and reduced renal perfusion
4 types of kidney diseases that cause acute kidney injury
Vascular (cholesterol emboli, renal vein thrombosis)
Glomerular (acute glomerulonephritis, hemolytic uremic syndrome)
Interstitial (acute interstitial nephritis, infection, myeloma kidney)
Tubular (ischemic or nephrotoxic acute tubular necrosis)
Where in the nephron do urinary casts usually form
Distal convoluted tubule
2 common causes of death in patients with acute tubular necrosis
Infections
GI bleed
What is the primary protein in the slit diaphragm of pedicels?
Nephrin
Why should we care about microalbuminuria?
Suggestive of early glomerular damage
We look for it in diabetics to predict diabetic nephropathy
What is nephrotic syndrome?
What is nephritic symdrome?
Nephrotic - protein leak through glomerular capillary wall
Nephritic - glomerular injury
5 things altered in nephrotic syndrome
Protineuria Hypoalbuminemia Edema Hyperlipidemia Lipiduria
What are the 2 mechanisms by which edema occurs in nephrotic syndrome?
Decreased serum albumin
Defect in sodium excretion -> volume expansion
Why is there hyperlipidemia and increased risk for thrombosis in nephrotic syndrome?
The liver tries to make more albumen and it also makes more of all proteins, including lipoproteins and clotting factors
6 things altered in nephritic syndrome
Microhematuria (sometimes casts) Leukocyturia Proteinuria Decreased GFR Hypertension Edema
3 genes most commonly mutated in hereditary glomerular disease
Nephrin
Podocin
WT-1
How do you treat hereditary glomerular disease?
ACEI
Renal transplantation eventually
Steroids don’t work
What is the mechanism of minimal change disease?
A circulating permeability factor acts directly on the podocyte, disrupting the permeability barier so proteinuria occurs
What molecule is expressed with minimal change disease?
CD80
What is the treatment for minimal change disease?
Steroids
What genetic polymorphism is more common in focal segmental glomerulosclerosis?
APOL1
What is membranous nephropathy?
Deposition of immune complexes in subepithelial space - glomerular basement membrane looks thickened
What is the antigen n membranous nephropathy?
Something on the podocyte, usually PLA2
What is the histologic pattern in membranoproliferative glomerulonephritis?
Mesangial proliferation
Thickening of glomerular basement membrane
C3 and IgG deposits
Membranoproliferative flomerulonephritis type 1 is associated with what infection?
Hepatitis C
What 2 diseases exhibit pulmonary-renal syndrome?
Goodpasture’s
ANCA-associated vasculitis
Crescents are ssociated with what disease process?
Rapidly progressing glomerulonephritis
Where are crescents? What 2 cells types are they made of?
Bowman’s capsule
Macrophages and parietal epithelial cells
Which infection is most common before post-infectious glomerulonephritis?
Group A strep (GAS)
In IgA nephropathy, wheredoes IgA usually deposit?
Mesangium
What is the mechanism of IgA nephropathy?
IgAs have abnormal sugars and are not cleared as easily, resulting in circulating complexes
What is the systemic disease that results in IgA nephropathy?
Henoch-Schonlein purpura
What is a pauci-immune renal vasculitis
Small vessel vasculities of the kidneys without evidence of immune complex deposition
What autoantibody is often present in pauci-immune renal vasculitis?
ANCA
What are the 2 most common antigens for ANCA?
Myeloperoxidase
PR-3
Cryoglobulins are most frequently associated with ________ infection
Hepatitis C
What do maltese crosses and oval fat bodies refer to?
The refractile pattern of lipiduria
3 complications of nephrotic syndrome
Hypercoagulability
Increased infections
Less vitamin D
3 things in general management of nephrotic syndrome
Low-salt diet
Diuretics
Blood pressure control
What is the main pathologic change in minimal change disease? What imaging modality is used to see it?
Elecron microscopy shows foot process fusion (but really foot processes are disrupted and proteinuria occurs)
What are 3 diseases associated with focal segmental glomerulosclerosis?
HIV associated nephropathy
Sickle cell
Obesity
What toxin can lead to membranous nephropathy?
Mercury
What is abnormal in membranoproliferative glomerulonephritis type II?
Low C3 and C4 via the alternative complement pathway
Are adjacent podocyte feet from the same cell or different cells?
Different! They alternate
5 clinical syndromes of glomerular disease
Asymptomatic hematuria/proteinuria
Acute nephritic syndrome (hematuria/protinuria + ARF)
Rapidly progressive nephritic syndrome
Nephrotic syndrome (massive proteinuria, hypoalbuminemia, edema)
Chronic renal failure
What are the 6 ‘nephritic’ diseases?
Benign familial hematuria (thin basement membrane disease)
Alport’s disease
IgA nephropathy
Postinfectious glomerulonephritis
Focal necrotizing/crescentif glomerulonephritis
Lupus glomerulonephritis
What is mutated in both thin basement membrane disease and Alport’s disease?
Collagen IV
What is the triad of Alport’s disease?
Nephritis
Deafness
Ocular lesions
What is the inheritance pattern of Alport’s disease
X-linked
I presume recessive
What population does Henoch-Schonlein Purpura most commonly occur in?
A starry sky immunoflourescence pattern occurs in which disease?
Postinfecious glomerulonephritis
What is the difference between membranous disease and membranoproliferative disease (both 1 and II)
Immune aggregates between the basement membrane and the podocyte
Immune aggregates in the basement membrane
I - antibodies
II - complement
3 types of IF staining in focal segmental necrotizing and crescentic glomerulonephritis
Linear - basement membrane itself is the antigen (Goodpasture’s, anti-GBM)
Granular - immune complex-mediated (IgA, SLE, endocarditis, etc)
No staining - pauci-immune (vasculites)
What is the difference between Goodpasture’s and anti-glomerulobasement membrane disease?
Renal limited: AGBM
Renal + lung: Goodpasture’s
What Ig is anti-GBM and Goodpasture’s?
IgG
What are the 6 renal lupus classifications?
I: No or minimal changes II: Mesangial glomerulitis III: Focal, segmental glomerulonephritis IV: Diffuse glomerulonephritis V: membranous nephropathy VI: Renal failure
2 mechanisms of hyperfiltration injury
Circulating factors
Mechanical stress
What 4 things are associated with membranous glomerulopathy 15% of the time?
Bugs - infections
Drugs - rheumatoid meds
Tumors
Rheum - SLE
What is the mechanism for membranoproliferative glomerulonephritis?
Subendothelial deposits cause injury to the endothelial cell
It retracts and puts a new layer of basement membrane between the deposit and itself
Is renal amyloidosis hypo or hypercellular?
Hypocellular - amyloid deposits wipe out the glomerulus and deposit in vessels
What does amyloidosis look like on EM?
Spilled spaghetti
What 2 kidney lesions does diabetes cause?
Hyaline arteriolar disease
Diabetic glomerulosclerosis
What happens in diabetic glomerulosclerosis?
Expansion of the mesangium
Basement membrane thickening
Mesangial lysis (they make so much basement membrane they kill themselves)
Wat is the gross appearance of the kidney in hypertensive renal disease?
Finely granular surface fromscarred glomeruli
What happens to the kidney in hypertensive renal disease (2)?
Medial and intimal thickening
yaline deposition
What happens in malignant/accelerated hypertensive renal disease?
Renal vasculature injury
- > fibrinoid necrosis, hyperplastic arteriolitis (ok inflammation)
- > increased renin
- > viscious cycle
What is uremia?
Dysregulation of stuff when there is severe loss of all renal functions
3 other things that get fucked up when your kidney is really fucked
Erythropoietin -> anemia
Renin -> hypertension
Vitamin D -> osteomalacia
Within what time frame must urinalysis be done in?
2 hours of collection
Or refrigerated if longer (but less than 24 hours)
What can cause a false positive on a urinalysis glucose screen? A false negative?
Jar is left open
Vitamin C
What does nitrite in the urine mean?
Gram negative bacteria
What do hyaline casts indicate?
They are normal
Hypo and hypernatremia refer to the concentration of sodium where?
In the serum
NOT total body
Urine can be _____ times more concentrated than plasma
4
What 2 things does ADH/vasopressin do?
Increase renal water reabsorption
Vasoconstriction
What is hte most common electrolyte disturbance in hospitalized patients?
Hyponatremia
What is a common mechanism of hyponatremia? What are 2 ways this can occur?
Elevated serum osmolality from a solute other than sodium
Hyperglycemia
Mannitol/glycerol administration
2 conditions that cause isotonic hyponatremia
Lab artifact:
Hyperlipidemia
Hyperproteinemia (like multiple myeloma)
Explain lab artifact isotonic hyponatremia
Plasma osmolality is normal but there is less water content *because of hyperlipiedmia or hyperproteinemia)
It is a laboratory artifact of flame photometry and a sodium-sensitive electrode will yield a normal value
Deficiency in what hormone causes hypovolemic hyponatremia?
What about euvolemic hyponatremia?
Mineralocorticoid
Glucocorticoid
4 causes of hypervolemic hyponatremia
Congestive heart filaure
Hepatic cirrhosis
Nephrotic syndrome
Advanced chronic or acute renal failure
What is serum osmolality like in hypernatremia?
It is always increased
What is diabetes insipidus?
Excessive thurst and excretion of lots of dilute urine. Reuction of fluid intake does not concentrate urine
What are the 2 kinds of diabetes insipidus?
Central - ADH/vasopressin is not made
Nephrogenic - insensitiity to ADH/vasopressin
Equation for amount of water needed to treat someone with hypernatremia
0.6*body weight in kg * [actualNa/desiredNa-1]
What is effective arterial blood volume?
Volume of blood detected by volume sensors in the arteries
What are the 4 categories of volume sensors?
Low-pressure baroreceptors - veins
High-pressure baroreceptors - carotid and aortic body
Intrarenal sensors
Hepatic and CNS sensors
What is the end product of the RAAAS?
Aldosterone
4 substances that decrease sodium reabsorption
Natriuretic peptides
Prostaglandins
Bradykinin
Dopamine
4 substances that increase sodium reabsorption
Angiotensin II
Aldosterone
Catecholamines
Vasopressin/ADH
What does sympathetic stimulation do to natriuresis?
Increases sodium reabsorption
What are 3 ways Na gets reabsorbed in the distal colvoluted tubule?
- Na channels
- NaCal cotransporter
- Na/H antiporter
These are all on the luminal side
How does sodium get into the principal cells of the cortical collecting duct?
Na enters and is exchanged for K
What is Bartter’s syndrome? Where in the kidney is the defect?
A mutation in the Na/K/2Cl cotransporter in the thick ascending loop of Henle?
Hypokalemia Hypomagnesemia Metabolic alkalosis High renin High aldosterone Increased calcium excretion Normal blood pressure
What is Gitelman’s syndrome? Where in the kidney is the defect?
A mutation in the Na/Cl cotransporter in the distal tubule
Hypokalemia
Hypomagnesemia
Metabolic alkalosis
Reduced excretion of calcium
4 serum changes in stats of volume contraction
Increased BUN:plasma creatine ratio (>15)
Metabolic alkalosis if upper GI fluid loss
Metabolic acidosis if lower GI loss
Increased hematocrit and serum albumin
6 diseases of nephrotic syndrome
Minimal change disease
Focal segmental glomerulosclerosis
Membranous nephropathy
Membranoproliferative nephropathy
Diabetes mellitus
Systemic amyloidosis
What are 3 changes in cirrhosis that cause underfilling of the arterial circulation?
Hepatic and portal hypertension
Aplanchnic vasodilation
Hypoalbuminemia
How does acetazolamide work?
Blocks carbonic anhydrase -> bicarb wasting -> metabolic acidosis and some diuretic action
Works in the proximal tubule
How do loop diuretics work?
Inhibit Na/K/2Cl cotransporter in thick ascending limb
How do thiazide diuretics work?
Inhibit the Na/Cl transporter
Blocking sodium entry
In distal convoluted tubule
How do triamterene and amiloride diuretics work?
Sodium channel blockers in collecting duct
How does spironolactone work?
Inhibits aldosterone
What are 2 direct sodium channel blocker diuretics?
Triamterene
Amiloride
How do the osmotic thresholds for thirs and ADH compare?
The threshold for thirst is a little higher (a few mOsm/kg)
2 states that increase ADH. Which is stronger?
Hyperosmolality
Hypovolemia
Hypovolemia overrides if osmolality and volume are opposing
3 causes of hypovolemic hyponatremia
Hemorrhage (due to rehydration without adequate Na intake)
Plasma volume and extracellular fluid losses
Decreased aldosterone as in addison’s disease
3 causes of hypervolemic hyponatremia
CHF
Cirrhosis
(both these cause release of ADH due to reduced effective blood volume)
Severe renal failure (the kidneys can’t excrete water)
Which type of diuretic impairs dilution and are a frequent cause of hyponatremia, particularly in the elderly?
Thiazides
3 treatments for hypervolemic hyponatremia
Water and salt restriction (giving salt is a frequent mistake but it worsens the edema!) Loop diuretics (but not thiazides, which can worsen) Inotropes if CHF
What is the underlying cause of symptoms of hyponatremia? What are some of them (8)?
Cerebral edema
Anorexia, nausea, vomiting
Weakness, lethargy, confusion
Seizures, death
If hyponatremia is chronic or uf unkonown duration, you slow correction to avoid what?
Central pontine myelinosis (osmotic demyelenation syndrome)
3 things in treatment of euvolemic hyponatremia
Seizures -> hypertonic saline
Asymptomatic -> water restriction and correction of underlying disorder
ADH/vasopressin antagonists
How does hypernatremia develop since we have a strong thirst reflex?
When patients don’t ave access to water
CNS problem that impairs thirst
What are 2 things that can be mutated in congenital nephrogenic diabetes insipidus?
AVP receptor (X-linked recessive) Aquaporin 2 (autosomal R or D)
How do you treat nephrogenic diabetes insipidus?
Vasopressin receptor antagonsts like tolvaptan
What is the cause of gestational diabetes insipidus?
Release of vasopressinase from the placenta during the second half of pregnancy
What is the job of the high-pressure baroreceptors?
Maintain mean arterial pressure by normalizing ECF volume
What is glomerulo-tubular balance?
Changes in GFR induce a proportional change in the rate of proximal tubular sodium reabsorption
Part of renal autoregulation
Where is most of the glomerular filtrate reabsorbed?
Proximal tubule
How is the sodium gradient maintained in the proximal tubule? (so that sodium will go into the cell)
Na/K ATPase at the basolateral membrane puts sodium into the blood
What does post-infectoius glomerulonephritis look like under imaging? (light, IF
Light microscopy - hypercellular, inflamed glomeruli
IF - granular
EM - large, subepithelial lump
What are the 3 types of rapidly progressing glomerulonephritis?
They describe the immunoflourescence patterns
Linear - antibodies against the glomerular basement membrane
Granular - immune complex deposition
Pauci-immune - ANCA-positive vasculitis
What is seen on urinalysis in acute tubular necrosis?
Brown granular casts
These were once the tubular cells
3 endogenous substances that affect internal K balance
Insulin
Catecholamines (NE, epi)
Aldosterone (maybe and if so its role is small)
What channel does K use to get out of the cells in the ascending limb of the loop of henle?
ROMK
Since aldosterone and cortisol bind to the mineralocorticoid receptor on cells in theascending limb of the loop of henle, how do we reduce the effects of cortisol?
Enzyme 11BOH-SDH turns cortisol into cortisone so it can’t bind
What can cause a spirous low serum K? High serum K?
High WBC count
High platelet count
How does hypomagnesia result in hypokalemia?
Mg prevents the K+ channel in the renal rubule from releasing potassium
Without Mg, renal K+ wasting occurs
Are men or women more likely to have hypertension?
Their risks are equal
Is systolic or diastolic blood pressure a more important cardiovascular disease risk factor in people over 50?
Systolic
What is the Guyton hypothesis of essential hypertension? (6)
Primary defect in renal sodium excretion from lower perfusion pressure
- > increased plasma volume
- > increased cardiac output
- > overperfusion of organs
- > autoregulatory increased in systemic vascular resistance
- > increased blood pressure
What is the cellular model of essential hypertension? (6)
In vascular smooth muscle cells
- > Na/K ATPase inhibitor
- > increased intracellular Na
- > Na/Ca exchanger doesn’t work (it puts Na in and calcium out)
- > SMC contracts
- > increase in systemic vascular resistance
- > increase in blood pressure
What is the most important thing to do in hypertension management?
Stop smoking
How do we define hypertension?
The level of blood pressure at which the benefits of therapy outweigh the risks
How do you calculate mean arterial pressure?
(2*DBP + SBP)/3
What are 3 proposed mechanisms of impaired natriuresis (the kidney excretes less Na than it should)
- Having less nephron mass -> decreased exretory ability
- Increased RAAS and sympathetic input -> more proximal tubular Na reabsorption
- Increased vascular resistance -> reduced renal blood flow
What turns angiogensin I into angiotensin II?
ACE (angiotensin converting enzyme)
What are 2 causes of renal artery stenosis? What are typical patient populaitons for each?
Fibromuscular dysplasia 50 years old and smokers and men
2 clinical features that suggest primary hyperaldosteroneism
Hypokalemic metabolic alkalosis
Resistant hypertension
What is the mineralocorticoid escape mechanism?
A mysterious mechanism where in hyperaldosteronism, sodium retention and edema don’t occur
What is pheochromocytoma?
A benign tumor of the adrenal medulla that makes catecholamines
What is a hypertensive crisis?
Acute management of elevated blood pressure plays a decisive role in outcome
Why is determining if hypertensive neuroretinopathy is present important?
If present, it signifies a systemic hypertensive vasculopathy (with fibinoid necrosis and obliterative arteriopathy)
What are the 2 findings that caracterize malignant hypertension?
Elevation of blood pressure
Widespread acute arteriolar injury
What is the most characteristic feature of malignant hypertension? What causes it?
Cotton-wool spots on the fundoscopic exam
From ischemic infarction of retinal nerve fiber bundles
From proliferation of vascular endothelium -> occlusion
What is goal blood pressure in patients with diabetes or chronic kidney disease?
What drug class reduces hypertension by decreasing cardiac output and total peripheral resistance? Just CO? Just TPR?
Non-dihydropyridine calcium channel blockers (verapamil)
Beta blockers
Dihydropyridine calcium channel blockers (amlodipine)
What drug classes reduces hypertension by decreasing cardiac output and total peripheral resistance?
Non-dihydropyridine calcium channel blockers
Where is most of the body’s potassium?
Intracellular fluid
What are 2 situations when K+ moves from intracellular fluid to the extracellular fluid?
Acidemia
Hyperosmolality
How does insulin react to K+?
Their levels are proportional and dependent boht ways
Increased insulin moves K+ into cells
How do beta-2 agonists affect K+?
Put K+ into cells
How does exercise affect K+
Muscle inury
- > leakage of K+ into extracellular fluid
- > hyperkalemia
Athletes redistribute K+ into the muscles -> hypokalemia
Which way does Na/K ATPase go?
3 Na out
2 Na in
Where in the kidney do disorders of renal K+ handling occur?
Collecting duct
Either addition or reabsorption)
Is adaptation to changes in Na or K intake faster?
Na
What is pH?
-log[H+]
What is the body’s normal pH range?
7.35-7.45
What is ammonia trapping?
NH3 diffuses into the lumen
Binds H+
It becomes NH+, which can’t get back through the membrane of the tubule
What size molecule does not pass through the glomerular filter?
60,000 daltons
What prevents red blood cells from getting into Bowman’s space?
Fenestrated epithelium (the holes are too small)
Where is the Na/K/2Cl cotransporter?
The thick ascending limb of Henle
Where does ammonioagenesis occur?
Proximal tubule cells
When is bicarbonate synthesized?
When there is no HCO3- in the tubular lumen
What is the formulat for net acid excretion?
NH4+ excretion + titratable acid excretion - HCO3- excretion
What is winter’s formula?
Expected CO2 = 1.5*bicarb + 8 +-2
TO see if appropriately respiratory compensaiton
How do you tell if pH is being metabolically or respiratorily compensated for?
Compensation is the same way as the pH
Cause is the opposite way
Where does mannitol work?
How does it work?
Proximal tubule
It is an osmotic diuretic
5 adverse effects of loop diuretics
Decreased K Decreased Mg Decreased hypocalcemia Gout attack Metabolic alkalosis
When do you use ethacrynic acid?
When you want loop diuretic effects that aren’t sulfa drugs
Where do loop diuretics work?
How do they work?
They inhibit the Na/K/2Cl cotransporter
Where do thiazide diuretics work?
How do they work?
Distal tubule
Inhibit Na/Cl cotransporter
What are 2 ways thiazide diuretics reduce hypertension?
Decrease plasma colume
Decrease cardiac output
Thiazides can cause hyper_______ and hyper_______
Hypercalcemia
Hyperglycemia (in people with impaired glucose tolerance)
How does chronic kidney disease alter thiazide diuretic response?
Thiazides become less effecteive because less drug reaches the site of action
You need a more effacious one at GFR
How do potassium sparing diuretics work?
Bind to the aldosterone-dependent Na/K exchange site and prevent aldosterone from reabsorbing
How do thiazides and loop diuretics affect uric acid?
They increase them
Is there cross-reaction between sulfonamide antibiotics and diuretics?
No
4 side effects of ACE inhibitors
Cough (from bradykinin not being broken down)
Hyperkalemia
Transient rise in serum creatinine
Angioedema
3 side effects of ARBs
Hyperkalemia
Transient rise in serum creatinine
Angioedema
Which calcium channel do CCBs block? What does this accomplish?
L-type
Arterial vasodilation -> decreased peripheral vascular resistance
What are the 2 classes of calcium channel blockers? What is the difference in their effects?
Dihydropyridines - peripheral and cardiac vasodilators
Non-dihydropyridines - cardiac stuff (negative inotropic activity)
Non-dihydropyridines inhibit what enzyme?
Dihydropyridines inhibit what enzyme?
CYP450
3A4. CYP450 is an isoenzyme of 3A4, whatever that means
How do hydralazine and minoxidil work?
Increase intracellular cGMP
- > relaxaiton of arterial smooth muscle
- > decreased systemic pressure and contractility
What is the suffix for alpha-1 receptor blockers?
-azosin
Terazosin
Doxazosin
Prazosin
How do alpha-1 receptor blockers work? What are they used for?
Peipheral postsynaptic blockade
- > decrease in arterial tone
- > relaxes smooth muscle of bladder neck
They are used for BPH
What are 2 alpha-2 receptor agonists we care about?
Clonidine
Methyldopa
How does bone act as a buffer?
In acidosis, osteoblasts are suppressed and osteoclasts are stimulated
Do we ingest/make an exces of acid or base?
Acid
How does the kidney transport hydrogen into the urine?
Sodium-hydrogen exchanger
What are the 2 main buffers in the urine?
TItratable acids (complexing of a hydrogen ion toa filtered acid anion) Ammonia
How does hyper/hypokalmeia affect ECF pH?
Hypokalemia -> alkalosis
Low K+ causes H+ shif into cells
Increased H+ in tubule cells means more is excreted
High K+ causes H+ to be inappropriately retained in the ECF
What is the bicarb equation?
H+ + HCO3- H2CO3 H2O + CO2
That is the expected increase in bicarbonate in respiratory acidosis in acute and chronic settings?
Acute: dHCO2- increases by 1 mEq/L for every 10 mmHg increase in PCO2
Chronic: dHCO3 increases by 4 mEq/L for every 10 mm increase in PCO2
What are the 2 steps of metabolic alkalosis?
Generation Miaintenance (always the kidney's fault)
In what case do you give hypertonic saline?
Seizures
Why does ADH cause hyponatremia?
It causes reabsorption of water, not sodium
Which diuretic can cause hyponatremia?
Thiazides
What causes euvolemic hyponatremia?
Syndrome of inappropriate ADH secretion
When do you give D5W?
For volume expansion in cases of low blood sugar or high sodium
What does insulin do to potassium?
Shifts it intracellularly
What does increased blood pH do to potassium?
Shifts potassium extracellularly
Because of the K/H exchanger
IN what state are peaked T waves seen on an EKG?
Hypokalmia
What does beta2 input do to potassium?
Shifts it intracellularly
What is the effect of increased tubular flow on potassium secretion?
Increased tubular flow makes secretion easier (so, more) because the fluid goes away
What is contraction alkalosis?
Loss of chloride-rich fluid
How does chloride afect blood pH?
Chloride depletion results in resporption of bicarbonate by the kidney
Thus, it maintains metabolic alkalosis
How does aldosterone contribute to alkalosis?
It induces H+ ATPase activity
What are 2 causes of chloride-resistant metabolic alkalosis
Hyperaldosteronism
Cushing’s syndrome
Equation for the expected increase in CO2 in metabolic alkalosis
dCO2 = (0.25 to 1.0)*HCO3
How do you treat chloride-responsive acidosis and chloride-resistant alkalosis?
NaCl infusion or KCl
Block mineralocorticoid effect with spironolactone or amiloride
How do you calculate a urine anion gap? What does it mean?
Na+K - Cl
Negative -> ammonia production in kidney is occuring
Positive -> renal ammonia production impaired an a renal tubular acidosis is present
Is acetazolamide a sulfa drug?
Yes
What is the results of inhbiting the Na/K/2Cl transporter with loop diureteics?
Medulary intersitium decreases tonicity
-> inhibition or reabsorption of water
Can you use loop diuretics on edema caused by calcium channel blockers?
No
Only cardiovascular, renal, or hepatic disease
3 adverse effects of spironolactone
Hyperkalemia
Gynecomastia
Amenorrhea
Eplerenone also does 1 and 3
What are 2 sodium-channel blocker diuretics we care about?
Triamterene
Amiloride
What is the suffix for ARBs?
-sartan
Angiotensin II receptor blockers
What is the mechanism of action of calcium channel blockers?
L-type channel block
- > less intracellular calcium in muscles
- > inhibition of intracellular phosphodiesterase
- > increased GMP
- > inhibition of vascular SMC contractility and cardiac conduction
What is the difference in target between dihydropyridines and nondihydropyridines?
Dihydropyridines are selective for L-type Ca channels in blood vessels
Non-dihydropyridines bind equally to cardiac and vascular L-type Ca channels
What are 2 direct vasodilators we care about?
Hydralazine
Minoxidil
How doe smnoxidil work?
Potassium chanel opener
-> hyperpolarizaiton of cell membranes
How does hydralazine work?
Alters calcium metabolism messing up the contractility somehow of the vasculature
What suffix is for alpha-1 blockers?
-zosin
How does clonidine work?
Stimulates alpha-2 adrenergic receptors
Decreases peripheral vascular resistance
Inhibits norepinephrine
What is the difference between hypertensive urgency and emergency?
Urgency - severe elevation
Emergency - BP >180/120 with organ dysfunction
How does sodium nitroprusside work?
Nitric oxide donor
Activates guanyl cyclase
-> myosin dephosphorylatin
-> VSMC relaxation
Which hypertension drug is light-sensitive and requires reconstitution in a vial?
Sodium nitroprusside
What is the definition of chronic kidney disease?
A permanent reduction in GFR
6 causes of chronic kidney disease
Diabetic nephropathy Hypertensive nephrosclerosis/renal vascular disease Glomerulonephritis Polycystic kidney disease Interstitial nephritis Obstruction
In chronic kidney disease, wthe rise of what 2 substances occurs to maintain balance?
FGF-23
Parathyroid hormone
What is the most important factor in decreasing the progression of kidney disease?
Blood pressure control
When is dialysis initiated?
When the risks of uremic complications exceed the risks of dialysis
What are the 3 ways heodialysis can be sceduled?
3 times per week
Short daily
Nocturnal
What are the 3 typical locations for arteriovenous shunts for hemodialysis?
Radiocephalic
Brachiocephalic
Brachiobasilic
Where does a dialysis catheter go?
Inernal jugular (so it’s a port I think)
3 limittions of dialysis
Uremia may not improve all the way
Difficult to remove enough volume to achieve euvolemia
Hperphosphatemia can ocure
What is warm and cold ischemia for a kidney transplant?
Warm - time from cardiac death/clamping in doner
Cold - time from cold perfusion to recipient anastomosis (24-36 hours)
What are the 2 pathways of T cell activation in transplant rejection?
Direct: Recipient T cells recognize intact donor HLA antiens on donor APCs
Indirect: recipient T cells recognize donor HLA antigen fragments on host APCs. This is the ‘normal’ mechanism of activation
What happens to CD4 Th cells when actiated?
They differentiate nto various subtypes depending on the stimulus and environment
Which 3 cytokines do TH1 cells make?
IFN-Y
TNF-a
IL-2
Is Th1 or Th2 the dominant immune response in acute allograft rejection?
Th1
Which cells is HLA class 1 on? HLA class II?
HLA/MHC 1 - all cells
HLA/MHC 2 - APCs
What are the 2 modes of transplant rejection?
Cellular (T-cell)
Antibody (B cell)
What are the 2 types of cellular kidney transplant rejection?
Tubulitis -> Banff class I
Vasculitis -> Banff class II
3 criteria to determine if antibody-mediated kidney rejection is occuring
peritubular capillary C4d staining
Graft damage
Donor specific antibodies
2 1st degree agents
2 second degree agents
3rd degree agents
For immunosuppression to limit immune graft damage
Calcineurin inhibitors cyclosporine, tacrolimus
Proliferation inhibitors MMF, sirolimus
Prednisone
How do NSAIDS work?
They block cyclooxegenase 1 and 2, resulting in lack of prostaglandin and thromboxane production
Which beta-blocker do we like to use in chronic kidney disease?
Metroprolol because its half-life is not prolonged
4 drug classes that can causehyperkalemia in chronic kidney disease
POtassium-sparing diuretics
ACE inhibitors
ARBs
Digoxin
6 things to give for hyperkalemia if EKG cheanges are present and their 3 different categories
To antagonize cardiac conduction abnormalities:
Calcium gluconate
Sodium bicarbonate
To shift K+ Intracellularly:
Glucose + insulin
Albuterol nebs (super hoigh doses)
To remove K+ from the body:
K exchange resin
Hemodialysis
How does Kayexalate K+ exchange resin work?
Binds K+ in exchange for Na+ in the gut
How does Patiromer/Veltassa K+ exchange resin work?
Exchanges Ca++ sorbitol for K+ in the gut
What are the 5 stages of chronic kidney disease?
1 - kidney damage, normal GFR 2 - kidney damage, mild GFR decrease 3 - moderate 4 -severe 5 - kidney failure
They all have GFR requirements
Wt which CKD stage do you need to renally dose drugs?
3-5
How do you deal with diuretic resistance in CKD?
Synergistically combine diuretics that act at different sites of the nephron
How does serum phosphate affect serum calcium leels?
They are inversely proportional
High phosphate -> lowers calcium
What is the trade-off hypothesis in chronic kidney disease?
kidney failure
- > phosphorus is retained
- > calcium is lowered
- > parathyroid release
- > excretino of phosphate and restoration of calcium levels
Eventually the renal tubules can no longer respond, bone disease occurs, and sytemic toxicity may happen
How does the kidney compensate for hydrogen ions in CKD?
Increase in NH4+
What are 4 reasons why anemia occurs in CKD?
Decreased erythropoietin
Shortened RBC lifespan, possibly due to a uremic toxin
Blood loss, possibly due to abnormal coagulation
Marrow fibrosis
What are 3 reasons why hypertension occurs in CKD?
Expansino of extracellular fluid volume (reduce ability to excrete sodium)
Incresed RAAS
Autonomic dysfunction and baroreceptors are insensitive
What is the number one thing to do to reduce CKD progression?
Treatment of hypertension with ACEIs or ARBs
What is a disadvantage of a catheter vs arteriovenous fistula/graft? An advantage?
Disadvantage - infection, mostly Staph
Advantage is ready immediately vs. weeks
Peritoneal dialysate has a lot of _____ to provide a high oncotic pressure
Dextrose
Why doesn’t the unterovesice junction have a valve?
The ureter goes into the bladder at an angle and this works
What are radio-paque stones made out of?
Semiopaque?
Not radiopaque (soo radiolucent?)
Radiopaque - calciu oxalate and phosphate
Semiopaque - magnesium ammonium phosphate
Other - uric acid, cystine
5 risk factors for kidney stones
Hypercalcemia
Increased uric acid
Low pH
Decreased volume
Bacteria
5 consequences of urinary tract obstruction
Hyeronephrosis, hydroureter
Infection
Chronic obstructive pyelonephritis
Renal failure
Hypertension
What are the 2 parts of the female intrinsic urinary sphincter?
Bladder neck muscle fibers
Mid-urethral complex
What are the 3 parts of the male intrinsic urinary sphincter?
Bladder neck circular muscle fibers
Smooth muscle of prostate and membranous urethra
What are the effects of parasympathetic (1) and sympathetic action (2) on the bladder?
PS: detrusor contraction
S: inhibition of detrusor, increased tension in smooth muscle of bladder neck and proximal urethra
What nerves are the somatic innervation of the bladder?
S2-S4
Which 3 parts of the brain provide input to micturition?
Cortex (inhibitory)
Cerebellum and brainstm (facilitatory)
What are the 5 steps of bladder emptying?
Storage
Emptying/voiding/micturition1. increase in bladder wall tension
2. Afferent input overcomes inhibitory signal
3. Pudendal nerve activity stops, external sphincter/pelvic floor relaxes, detrusor neurons discharge
4. Proximal urethra opens
5. BLadder contracts
What do hyperactive deep tendon reflexes suggest? Hypoactive deep tendon reflexes?
Hyper - upper motor nuerons are fucked
Hypo - lower motor neurons are fucked
What drug class do you use to manage overactive bladder?
Antimuscarinic agents
They inhibit involuntary bladder contractions and increase bladder capacity
4 side effects of antichoenergic therapy
Dry mouth
Constipation
Blurred vision
Drowsiness
Do drugs for urinary incontinence affect the afferent or efferent nerves?
Efferent
What is the goal of medical management of stress urinary incontinence? What are the 2 drug classes?
Goal is to increas bladder outlet resistance
Alpha agonists
Estrogen
What is the most common cause of pediatric hydronephrosis?
Uteropelvic junction obstruction
What is the most common renal abnormality?
Ureteral duplication
What is a ureterocele? Why is it a problem?
A cystic dilation of the part of the ureter that is within the bladder (intravesical part)
Can be obstructive or cause reflux
Where does the urachus go?
From the dome of the fetal blader to the allantois of the umbilical cord
It forms the median umbilical ligament after birth
What causes posterior urethral valves?
There are not supposed to be valsces there
They are from abnormal insertion of mesonephric duct on the cloaca before it divides into the urogenital sinus and anorectal canal
What is hypospadias? What is epispiadias?
Hypospadias is when the orifice of penile urethra is somewhere along the ventral aspect of the penis (the part facing forward when penis is erect)
Epispadias is when it is on
It is from abnormal fusion of urogenital folds from androgen insufficiency
What is chordee?
A fibrous band on the penis, causing it to curve
What is exstrophy?
Exposure of the bladder mucosa b/c abdominal wall is absent
What causes an exstrophy-epispadias complex?
Failure of separation of the primitive cloaca by the urorectal septum
What are the 5 parts of Potter sequence?
Renal agenesis Small amt of amniotic fluid Squished face Amnion nodosum Pulmonay hyupoplasia
What causes amnion nodosum? Why is ist bad?
Nodules of squamous cells on amniotic membrane b/c the baby sheds them.
Over time this erodes the surface of the amnion
What is the cause of death in renal agenesis?
Respiratory insufficiency (Potter sequence)
What causes prune belly/Eagle-Barrett syndrome?
Atrophy of anterior abdominal muscles due to megalocystis
Which kidney is less likely to form?
The left one is more comonly absent
What is renal ectopia? What are 2 complications?
When the kidney is not in the right place
May result in ureteral obstruction or discoid shape
Where are kidneys usually fused in horseshoe kidney? What is the most common complication?
They are usually fused at the lower pole
Increased incidence of urolithiasis
Which type of polycystic kidney disease presents earlier?
Autosomal recessive
What is the most common cause of renal cysts?
Dialysis
What other 5 organs can autosomal dominant polycystic kidney disease affect?
Hepatic cysts Mitral valve prolapse Diverticulosis Cerebral aneurisms (berry aneurisms) Pancreatic cysts
Where are the cysts in autosomal dominant PKD? Where are they in ARPKD?
AD - entire nephron
AR - collecting tubules
What happens to the liver in autosomal recessive polycystic kidney disease?
Portal hypertension from bile duct proliferation and periportal fibrosis
What causes multicystic dysplastic kidney?
Abnormal induction of metanephric blastema by uretal bud
What happens to a multicystic dysplastic kidney after birth?
If is nonfunctional, asymptomatic, and will involute over time
What is tubule cuffing on histology associated with?
Multicystic dysplastic kidney
What are 3 pediatric kidney tumors?
Congenital mesoblastic nephroma
Wilms tumor
What are the 3 components of a Wilms tumor?
Blastemal (small round blue cells)
Epithelial (tubules)
Stromal (fibroblastic)
What is associated with worse prognosis in Wilms tumor? Describe. Why is this bad?
Anaplasia
These are large, hyperchromatic cells with weird mitotic figures
It means these tumors are less chemosensitive
What is the stage of a bilateral Wilms tumor?
V (even though most cancers only go up to stage IV)
4 components of Beckwith-Weidemann syndrome
Wilms tumor
GIgantism
Macroglossia
Abdominal wall defects
4 components of WAGR syndrome
Wilms tumor
Aniridia (no iris)
Genitourinary malformation
mental Retardation
Which kidney is used for transplant?
Left because the renal vein is longer
Where do the renal vein and artery anastomosed to in a kidney transplant? Which side does the kidney go on?
External iliac vein and artery, usually on the right side
Which MHC do CD8+ cells respond to?
i
Which MHC do CD4+ cells respond to?
II
Which MHC/HLA is on all nucleated cells?
Cllass I
What are the 4 steps of T cell receptor activation?
Increased intracellular Ca2+ activates calmodulin
- > Calmodulin binds/activates calcineurin
- > calcineurin dephosphorylates nuclear transcription factor NFAT
- > NFAT induces cytokine transcription in the nucleus (IL-2)
What are the 3 steps of T cell proliferation after activation?
IL-2 and IL-15 activate JAK/STAT pathway
- > mTOR pathway
- > Nucleotide synthesis and cell cycle activation leading to clonal expansion
What are the 3 classifications of kidney donors?
Standard
Donation after cardiac death
Extended criteria
What are 2 inhibitors of T cell proliferation?
Myocphenolate mofetil mTOR inhibitors (siroliumus, everolimus)
What does the urinary tract consti of?
Real pelvis
Ureter
Bladder
What are the 2 routes of infection for a UTI?
Hematogenous
Ascending
What is the most common cause of ascending UTI?
E. COli
What do “O” antigens mean?
They make certain E. coli strains more resistant
What are the 3 kidneys in the embryo? What are the time points associated with each?
Pronephros (4 weeks)
Mesonephros (4 weeks-2 months)
Metanephros - 5 weeks - maturity)
All 3 kidney stages develop from the ________ within the ________
Nephrogenic cord
Urogenital ridge
What are the little bits of emryological kidneys within each somite called?
Nephrotomes
What is the joining of the nephrotomes called?
Mesonephric duct
The mesonephric duct is also called the _____
Wolffian duct
What does the mesonephric duct/Wolffian duct become?
Epididymus
Vas deferens
The paramesonephric duct is also called the ______
Mullarian duct
What does the paramesonephric duct/Mullerian duct become?
Oviducts and uterus parts
The Mullerian duct is also called the ______
Paramesonephric duct
Whe wolffian duct is also called the _______
Mesonephric duct
The ______ surrounds the ureteric bud
Metanephric blastema
What 4 things does the metanephric blastema become?
Ureter
Renal pelvis
Major calyces
Minor calyces
3 benign tumors of the kidney
Renal papillary adenoma
Angiomyolipoma
Oncocytoma
3 cell types in clear cell renal cell carcinoma
Clear
Granular
Spindle
What genetic disease is associated with Clear cell renal cell carcinoma?
Von Hippel-Lindau disease
What are the 4 renal cell carcinomas?
Clear cell
Chromophobe
Collecting duct
Familial
4 exposers that increase risk of transitional urinary tract cancers
Smoking
acrylamide
Schistosoma haematobium
Radiation
What is medullary sponge kidney?
A congenital disorder where cystic dilation of collecting tubules occurs
Autosomal dominant PDK is due to a defect in which protein? What is autosomal recessive PDK due to?
Polycystin
Fibrocystin
What is nephrophthisis-medullary cystic kidney disease complex?
A heritable disease where medullary cells die
In kidney failure how does an increased in volume of distribution affect
drug plasma concentration? A decreased volume of distribution?
They both increase plasma concentration
So, renal dosing usually means reduce med
What 2 drugs dilate the affsorium Naerent arteriole? Which drug constricts it?
Dopamine, caffeine
NSAIDS
What 2 drugs constrict the efferent arteriole?
ACEIs, ARBs
How do you calculate FENa?
urinary Na * plasma creatinine/(plasma Na*urinary creatinine)
What can cause peaked T waves?
Hyperkalemia
What electrolyte imbalance can lead to rhabdomyolysis?
Hypokalemia
What is the equation for renal clearance?
Urine concentration * urine flow/plasma concentration
What does angiotensin II doe to the glomerulus? What results does this have?
It vasoconstricts the afferent and efferent arterioles (but mostly the efferent)
This results in decreased GFR
What does the macula densa respond to?
Changes in NaCl delivery
Which hormone inserts aquaporins?
Aldosterone
Is the response to ADH or aldosterone faster?
ADH, since it prompts vesicle fusion and aldosterone goes all the way to the nucleus to induce transrption of Na+ channels and pumps
Is BUN/creatinine reabsorbed/secreted?
BUN is reabsorbed and creatinine is secreted
How long after infection does post-infectious glomerulonephritis occur?
2-3 weeks
What is the treatment for post-infectious glomerulonephritis?
Supportive
What is a bad complication of PIGN in adults?
Can become RPGN
What characterizes rapidly progressive glomerulonephritis?
Crescents in bowman’s space on H&E
This is fibrin and macrophages
How do you differentiate types of post-infectious glomerulonephritis
Immunoflourescence
Which disease results in thinning and splitting of the glomerular basement membrane?
Alport syndrome
What part of the kidney is renal cell carcinoma from?
Kidney tubules
What is the classic symptomatic triad in renal cell carcinoma?
Hematuria
Palpable mass
Flank pain
Where does the uteric bud branch from?
The mesonephric duct
How many people in the US have hypertension?
50-60 million
What does the Furnman criteria apply to?
Clear cell carcinoma
What is the fate of the ureteric bud? The metanephric blastema?
Urinary tract (urethra to tubules) Kidney