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DERM > RENAL > Flashcards

RENAL Flashcards

1
Q

pre-renal causes of AKI

A

reduced renal perfusion (fluid depletion/dehydration, sepsis, renal artery obstruction, reduced cardiac output)

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2
Q

post-renal causes of AKI

A

stones, tumours, BPH, obstruction in bladder/ureters/urethra

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3
Q

intra-renal causes of AKI

A

acute tubular necrosis, interstitial nephritis, vasculitis, GN, renal artery/vein obstruction

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4
Q

sings of AKI

A 
hyperkalaemia/hypokalaemia 
raised creatinine 
raised urea 
acidosis
reduced/no urine output
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5
Q

examples of fluid shift

A

ascites, effusions, capillary leak states (sepsis/burns)

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6
Q

causes of negative fluid balance

A

decreased input
increased output
fluid shift

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7
Q

renin is secreted in response to what

A

reduction in glomerular filtration rate

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8
Q

how is a reduction in the GFR detected

A

stretch receptors in the macula dense cells of the juxtaglomerular apparatus are stimulated

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9
Q

action of renin

A

angiotensinogen to angiotensin I

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10
Q

which enzyme converts angiotensin I to angiotensin II

A

ACE

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11
Q

what stimulates release of aldosterone

A

renin

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12
Q

effect of aldosterone release

A

increased sodium reabsorption in the DCT

increased excretion of potassium

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13
Q

what is renal artery stenosis

A

narrowing of the renal artery lumen

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14
Q

chronic elevation of angiotensin II results in what

A

cardiac and vascular hypertrophy

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15
Q

what does atrial natriuretic factor detect

A

atrial filling

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16
Q

what stimulates release of ANP

A

increased volume (increased atrial filling)

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17
Q

what does ANP do

A

inhibits sodium reabsorption in the DCT (opposes aldosterone)

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18
Q

mechanism of action of ACEIs

A

inhibits the formation of angiotensin II leading t vasodilatation

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19
Q

examples of ACEI

A

rampiril, lisonopril

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20
Q

mechanism of action of ARBs

A

block angiotensin II receptors on blood vessels/tissues

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21
Q

examples of ARBs

A

losartan

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22
Q

actions of ACEIs/ARBs on the CV system

A 
dilate arteries (reduce arterial pressure, preload and after load)
down regulate sympathetic adrenergic activity 
promote renal excretion of Na and water (reduces blood volume, venous pressure and arterial pressure)
inhibit cardiac and vascular remodelling associated with HTN, HF, MI
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23
Q

mechanism of action of a1 receptor blockers

A

block a1 adrenoceptors in the bladder and prostate, relaxing smooth muscle and reaching resistance to urinary flow and damage to kidneys from downstream obstruction

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24
Q

example of a1 receptor blocker

A

tamulosin

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25
Q

nephrotoxic side effects of gentamicin

A

acute tubular necrosis

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26
Q

nephrotoxic side effects of vancomycin

A

acute interstitial nephritis

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27
Q

nephrotoxic side effects of ACEIs

A

reversible acute renal failure (HTN/CHF)

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28
Q

nephrotoxic side effects of diuretics

A

reduced GFR
hypokalaemia nephropathy
polyuria
interstitial nephritis

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29
Q

nephrotoxic side effects of NSAIDs

A

AKI caused by sodium and water retention, reducing renal blood flow and direct kidney injury

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30
Q

what is the ‘triple whammy’ effect

A

the significant increase in harm that may result from the combined use of NSAIDs, ACEIs/ARBs and diuretics in high-risk individuals.

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31
Q

mechanism of action of the ‘triple whammy’ effect

A

NSAIDs constrict the blood flow into the glomerulus via the afferent arteriole by inhibiting vasodilator prostaglandins
ACEIs/ARBs decrease angiotensin II level/action, leading to reduced GFR by dilating the efferent arteriole
diuretics induced dehydration and blood volume reduction leading to insufficient renal haemodynamics and failure to maintain GFR

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32
Q

what is the definition of CKD

A

gradual loss of kidney function due to abnormal function or structure

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33
Q

what is the best measure of overall kidney function

A

GFR

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34
Q

what factors are taken into account when calculating eGFR

A

serum creatinine, age, gender, race

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35
Q

what advice should be given to patients before eGFR testing

A

avoid eating meat for 12 hours before

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36
Q

GFR for CKD stage 1

A

> 90

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37
Q

GFR for CKD stage 2

A

60-89

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38
Q

GFR for CKD stage 3

A

30-59

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39
Q

GFR for CKD stage 4

A

15-29

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40
Q

GFR for CKD stage 5

A

<15

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41
Q

effect of ageing on GFR

A

decreases with age

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42
Q

NICE guidance for patients over 70 with reduced GFR

A

stable GFR >45 is unlikely to be associated with CKD-related complications

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43
Q

GFR for CKD stage 3A and 3B

A

3A 45-59

3B 30-44

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44
Q

what does the suffix P mean in relation to CKD staging

A

proteinuria

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45
Q

common causes of CKD

A

diabetes, GN, pyelonephritis, renal vascular disease, polycystic kidney disease, hypertension

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46
Q

patients at higher risk of developing CKD

A 
diabetics
hypertension 
CVD
structural renal tract disease 
multi system disease with potential for renal involvement (eg SLE)
patients with a FH of CKD stage 5
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47
Q

common nephrotoxic drugs

A

NSAIDs
lithium
diuretics
ACEIs

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48
Q

lifestyle measures for management of CKD 1,2,3

A 
smoking cessation
weight loss
regular exercise and a healthy diet 
sensible alcohol consumption 
low salt
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49
Q

what is classed as progressive CKD

A

decline of more than 5 ml/min/1.73m^2 over 1 year OR more than 10 ml/min/1.73m^2 over 5 years

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50
Q

how often should BP be measured in patients with CKD

A

at least once a year

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51
Q

BP target s for patients with CKD

A

120-139 mmHg systolic and <90 mmHg diastolic UNLESS proteinuria/diabetic with microalbuminuria 120-129 mmHg systolic and <80 mmHg diastolic

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52
Q

recommended lab testing for CKD stage 1/2

A

eGFR, PCR/ACR yearly

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53
Q

recommended lab testing for CKD stage 3

A

eGFR, PCR/ACR, Hb, K+, Ca2+, phosphate 6 monthly (12 monthly if stable)

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54
Q

recommended lab testing for CKD stage 4

A

eGFR, PCR/ACR, Hb, K+, Ca2+, phosphate, HCO3, PTH 3 monthly

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55
Q

recommended lab testing for CKD stage 5

A

eGFR, PCR/ACR, Hb, K+, Ca2+, phosphate, HCO3, PTH 6 weekly

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56
Q

first line management of HTN (protein/microalbuminuria) in CKD

A

ACEIs (or ARBs)

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57
Q

when should ACEIs be reduced in dose or stopped

A

if there is more than a 25% fall in eGFR from the pre-ACEI value

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58
Q

indications for referral to nephrologist in CKD

A

acute renal failure
malignant hypertension
hyperkalaemia (>7 mmol/L)
nephrotic syndrome

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59
Q

what is renal bone disease

A

CKD is associated with elevated PTH, in association with low Ca and high phosphate, and inadequate renal vitamin D production

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60
Q

what type of anaemia is commonly associated with CKD

A

normochromic normocytic anaemia

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61
Q

what causes anaemia in CKD

A

inadequate production of erythropoietin

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62
Q

risk factors for urinary incontinence

A 
female sex 
pregnancy
vaginal delivery 
pelvic surgery 
pelvic organ prolapse 
raised IAP (chronic constipation, lung disease)
obesity 
menopause 
caffeine
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63
Q

incontinence may be caused by

A

neurological dysfunction
abnormalities of detrusor function
abnormalities of the sphincter apparatus (including surrounding pelvic floor muscles and tissue)
anatomical abnormalities

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64
Q

four main types of incontinence

A

stress
urge
mixed
overflow

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65
Q

what is stress incontinence

A

leakage of urine caused by effort or exertion or on coughing/sneezing

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66
Q

causes of stress incontinence

A

problem with the sphincter apparatus

neurological problem

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67
Q

what causes urge incontinence

A

overactivity of the detrusor muscle

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68
Q

what is urge incontinence

A

uncontrollable leaking of urine preceded by or accompanied by a sudden urge to void

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69
Q

what is overflow incontinence

A

large volume chronic retention due to bladder outflow obstruction resulting in leaking when the bladder can hold no more urine

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70
Q

what causes overflow incontinence

A

prostatic enlargement

bladder obstruction

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71
Q

complications of overflow incontinence

A

associated with increased risk of renal failure due to vesicouteric incompetence and hydrostatic pressure on the renal system

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72
Q

triggers for stress incontinence

A

coughing, sneezing, exercise, lifting or rising from sitting

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73
Q

tiggers for urge incontinence

A

running taps

cold weather

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74
Q

examination of incontinence

A

abdominal exam
PR (men)
pelvic (women)
neurological

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75
Q

investigations of incontinence

A

bladder diary for three days
urine dip
bladder scan

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76
Q

management of stress incontinence

A

pelvic floor exercises

recommend weight loss

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77
Q

management of urge incontinence

A 
bladder training (6 weeks)
oxybutynin if ineffective 
intravaginal oestrogen if atrophy 
recommend decreased caffeine intake and weight loss
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78
Q

urgent referral criteria for incontinence

A

non-visible haematuria if over 50
visible haematuria in any age group
recurrent/persistent UTI with non-visible haematuria if over 40
suspected levin mass

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79
Q

routine referral for incontinence

A

prolapse of the vagina that is symptomatic and visible

patients with a palpable bladder after voidinh/high post-void volume

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80
Q

consider referral for incontinence

A

persistent bladder/urethral pain
associated faecal incontinence
suspected neurological disease
voiding difficulties
suspected fistula (continuous incontinence)
previous surgery to correct incontinence
previous pelvic irradiation/cancer surgery

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81
Q

surgical management of stress incontinence

A

mid-urethral tapes such as tension/free vaginal tapes or transobturator tapes

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82
Q

secondary care management of urge incontinence

A

botox injections

sacral nerve stimulator

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83
Q

management of post-prostatectomy incontinence

A

pelvic floor exercises

84
Q

management of outflow incontinence

A

alpha blockers

5a-reductase inhibitors

85
Q

action of 5a-reductase inhibitors

A

inhibit the enzyme responsible for converting testosterone to dihydrotestosterone (important in development of BPH)
slows progression of BPH

86
Q

mechanism of action of a-blockers

A

relax the smooth muscle of the bladder neck, aiding non-obstructive voiding

87
Q

reversible causes of UI in older people

A

Delerium
Infection
Atrophic vaginitis
Pharmaceuticals (opiates, calcium antagonists, anticholinergics)
Physiological problems (anxiety, depression)
Excess urine output (high fluid intake, diuretics)
Reduced mobility
Stool impaction

88
Q

what are LUTS

A

lower urinary tract symptoms

89
Q

symptoms of BPH

A 
urinary frequency
nocturia 
urgency 
poor flow 
incomplete bladder emptying
90
Q

differential diagnosis of BPH

A 
bladder neck obstruction 
urethral stricture 
carcinoma in situ of the bladder 
Parkinson's disease 
cauda equina lesions 
nocturnal polyuria
DM
91
Q

examination of BPH

A

PR

92
Q

likelihood of prostate cancer with a raised PSA

A

20-25%

93
Q

investigation of BPH

A

PSA
uroflowmetry
measurement of post-ovoidal residual volume

94
Q

upper urinary tract

A

kidneys

ureters

95
Q

lower urinary tract

A

bladder

urethra

96
Q

what are the 5 layers anterior to the kidney

A 
renal capsule 
perinephric fat 
renal (deep) fascia 
paranephric fat 
visceral peritoneum
97
Q

muscles of the posterior abdominal wall

A

psoas major

quadrates lumborum

98
Q

vertebral level of the kidneys

A

left kidney T12-L2

right kidney L1-L3

99
Q

what is the clinical relevance of the hepatorenal recess

A

the most dependent part of the greater sac - fluid more likely to collect there in the supine position

100
Q

the right kidney is posterior to

A

liver
duodenum
ascending colon
right colic flexure

101
Q

the left kidney is posterior to

A

stomach
tail of pancreas
hilum of spleen
splenic vessels

102
Q

lymph from the kidneys drains where

A

lumbar nodes

103
Q

lymph from the ureters drains where

A

lumbar and iliac nodes

104
Q

what is the ureteric blood supply

A 
branches from;
renal artery 
abdominal aorta 
common iliac 
internal iliac 
vesical artery
105
Q

parts of a nephron

A 
glomerulus 
bowman's capsule 
PCT
loop of henle 
DCT
collecting duct
106
Q

how does urine drain from the kidney

A 
collecting ducts
minor calyx 
major calyx 
renal pelvis 
ureter
107
Q

anatomical sites of ureteric constriction

A

pelviureteric junction
crossing of the common iliac
vesicoureteric junction

108
Q

what is hydronephrosis

A

urine back pressure into the calyces compressed the nephrons within the medullary pyramids leading to renal failure

109
Q

where is the perineum

A

between the pelvic floor and skin

110
Q

what makes up the three points of the trigone

A

2 ureteric orifices

internal urethral orifice

111
Q

which muscle makes up the majority of the bladder wall

A

detrusor muscle

112
Q

2 routes for catheterisation

A

urethral

suprapubic

113
Q

what is contained in the spermatic cord

A 
testicular artery 
testicular vein
vas deferencs 
lymphatic vessels 
nerves
114
Q

the testis sit within a sac called the

A

tunic vaginalis

115
Q

what is a hyprocoele

A

excess fluid in the tunica vaginalis

116
Q

what are the three cylinders of erectile tissue in the penis called

A

right and left corpus cavernosum

corpus spongiosum

117
Q

blood supply to the penis

A

deep arteries of the penis (branches of the internal pudendal artery from internal iliac)

118
Q

blood supply to the scrotum

A

internal pudendal and branches from the external iliac

119
Q

lymph form the scrotum and penis is drained where

A

superficial inguinal nodes

120
Q

lymph from the testis drains where

A

to the lumbar nodes

121
Q

what are the specialised epithelium cells that overlie the glomerular capillaries called

A

podocytes

122
Q

which two cell layers separate the blood from the glomerular filtrate

A

capillary endothelium

podocytes

123
Q

what lies between the capillary endothelium and the podocyte epithelium

A

basal lamina

124
Q

what is the function of the mesangial cells

A

support

removal of debris

125
Q

what is the thick ascending limb of the loop of henle lined by

A

simple cuboidal epithelial cells with abundant mitochondria

extensive brush border

126
Q

cells of the juxtaglomerular apparatus

A

macula densa
juxtaglomerular cells
extraglomerular mesangial cells (or laces cells)

127
Q

the majority of the conducting parts of the urinary tract are lined by

A

transitional epithelium (urothelium)

128
Q

what cells make up the transitional epithelium

A

umbrella (surface) cells

129
Q

2 ways the transitional epithelium is specialised to its function

A

the variability in thickness of cells represents different states of distension
the apical surface of cells at the surface have a thickened membrane to provide a highly impermeable barrier

130
Q

types of epithelium in the female urethra

A

transitional

stratified squamous near termination

131
Q

types of epithelium in the male urethra

A

transitional
stratified columnar after prostate through the penis
stratified squamous at the tip of the penis

132
Q

what is osmolarity

A

concentration of osmotically active particles present in a solution

133
Q

which two factors influence the osmolarity of a solution

A

molar concentration

number of osmotically active particles present

134
Q

what is osmolarity of body fluids

A

300 mosmol/L

135
Q

what is the tonicity of a solution

A

the effect a solution has on cell volume

136
Q

2 major fluid compartments

A

ICF

ECF

137
Q

the main ions in the ECF are

A

Na
Cl
HCO3

138
Q

the main ions in the ICF are

A

K
Mg
-ve charge proteins

139
Q

juxtamedullary vs cortical nephrons

A

juxtamedullary are less numerous, travel deeper into the medulla and have a vasa recta that follows the loop of Henle

140
Q

what are the three renal processes required to produce and concentrate urine

A

glomerular filtration
tubular reabsorption
tubular secretion

141
Q

rate of excretion =

A

rate of filtration + rate of secretion - rate of reabsorption

142
Q

rate of filtration =

A

concentration in plasma x GFR

143
Q

rate of excretion =

A

concentration in urine x urine flow rate

144
Q

rate of reabsorption =

A

rate of filtration - rate of excretion

145
Q

rate of secretion =

A

rate of excretion - rate of filtration

146
Q

how do sympathetic nerves leave the spinal cord

A

cranial nerves

spinal nerves T1-L2 (thoracolumbar outflow)

147
Q

what do sympathetic nerves innervate

A

smooth muscle

glands

148
Q

how do sympathetic nerves get from the CNS to the kidneys, ureters and bladder

A

leave the spinal cord between T10 and L2
enter sympathetic chains but do not synapse
leave the sympathetic chains within abdominopelvic splanchnic nerves
synapse at the abdominal sympathetic ganglia located around the abdominal aorta
follow arteries to the organs they innervate

149
Q

how do parasympathetic nerves leave the CNS

A

within 4 cranial nerves (II, VII, IX, X) and sacral spinal nerves
(craniosacral outflow)

150
Q

how do parasympathetic nerve fibres get from the CNS to the kidney, ureters and bladder

A

kidneys and ureters - CNX

bladder - pelvic splanchnic nerves

151
Q

what types of nerve innervate the kidneys, ureters and bladder

A

sympathetic
parasympathetic
visceral afferents
(distal urethra and sphincter somatic motor)

152
Q

where is pain from the kidney normally felt

A

loin

153
Q

where is renal colic normally felt

A

loin to groin

154
Q

where is pain from the bladder felt

A

suprapubic

155
Q

where is pain from the perineal urethra felt

A

perineum (localised)

156
Q

how do visceral afferent get from the kidneys to the CNS

A

run alongside sympathetic fibres back to the spinal cord

enter between T11 and L1

157
Q

how do visceral afferent nerve fibres get from the ureters to the CNS

A

run alongside sympathetic fibres

enter between T11 and L2

158
Q

how do visceral afferent nerve fibres get from the bladder to the CNS

A

from the superior bladder (touching peritoneum)
- run alongside sympathetic fibres back to spinal cord
- enter between T11-L2
from the rest of the bladder (not touching peritoneum)
- run alongside parasympathetic nerve fibres back to spinal cord levels S2-4

159
Q

how do visceral afferent and somatic sensory nerve fibres get from the urethra to the CNS

A

visceral afferents
- alongside parasympathetic nerve fibres to spinal cord levels S2-4
somatic sensory
- within the pudendal nerve to spinal cord level S2-4

160
Q

how do pain fibres get from the testis to the CNS

A

visceral afferents run alongside sympathetic fibres back to the spinal cord levels T10-11
due to its close relationship to the scrotal wall, pain from testis can also present localised to the scrotum and/or groin

161
Q

which spinal cord levels are most important in control of micturition

A

S2-4

162
Q

femoral nerve innervates which compartment of the thigh

A

anterior

163
Q

obturator nerve innervates which compartment of the thigh

A

medial

164
Q

sciatic nerve innervates which compartment of the thigh

A

posterior

165
Q

superficial fibular innervates which compartment of the leg

A

lateral

166
Q

deep fibular innervates which compartment of the leg

A

anterior

167
Q

tibial nerve supplies which compartment of the leg

A

posterior

168
Q

three physical barriers to glomerular filtration

A 
glomerular capillary endothelium
basement membrane (basal lamina)
slit processes of podocytes in glomerular epithelium
169
Q

does the glomerular basement membrane have a charge

A

negatively charged

170
Q

forces that comprise the net filtration pressure

A

glomerular capillary blood pressure
bowman’s capsule hydrostatic pressure
capillary oncotic pressure
bowman’s capsule onctoic pressure

171
Q

what is normal GFR

A

125 ml/min

172
Q

what is the major determinant of GFR

A

glomerular capillary blood pressure

173
Q

extrinsic control of GFR

A

sympathetic control via baroreceptor reflex

174
Q

intrinsic control of GFR

A

myogenic mechanism

tubuloglomerular feedback mechanism

175
Q

effect of vasoconstriction of the afferent arteriole on GFR

A

decreases blood flow > decreased net filtration pressure > decreases GFR

176
Q

effect of vasodilation of the afferent arteriole on GFR

A

increases blood flow > increases net filtration pressure > increases GFR

177
Q

do changes in systemic arterial pressure result in changes in GFR

A

not necessarily
RBF and GFR are protected from changes in MABP over wide ranges
GFR stays quite constant unless at extremes

178
Q

myogenic auto regulation of GFR

A

if vascular smooth muscle is stretched (increased BP), it contracts thus constricting the arteriole

179
Q

tubuloglomerular feedback auto regulation of GFR

A

involved the juxtaglomerular apparatus

if GFR rises, more NaCl flows through the tubule leading to constriction of afferent arterioles

180
Q

effect of an increased bowman’s capsule fluid pressure on GFR

A

decreased GFR

181
Q

effect of increased capillary oncotic pressure on GFR

A

decreased GFR

182
Q

effect of decreased capillary oncotic pressure on GFR

A

increased GFR

183
Q

pressures opposing/favouring filtration

A

favouring - glomerular capillary fluid pressure, bowman’s caplsue oncotic pressure
opposing - bowman’s capsule fluid pressure, capillary oncotic pressure

184
Q

name a substance that is filtered, completely reabsorbed and not secreted

A

glucose

185
Q

name a substance that is filtered, not reabsorbed and not secreted

A

inulin

186
Q

name a substance that is filtered, partly reabsorbed and not secreted

A

urea

187
Q

name a substance that is filtered, secreted and not reabsorbed

A

H+

188
Q

clearance < GFR

A

substance is reabsorbed

189
Q

clearance = GFR

A

substance is neither reabsorbed nor secreted

190
Q

clearance > GFR

A

substance is secreted

191
Q

why is PAH used to calculate renal plasma flow

A

it if filtered, secreted and not reabsorbed ie it is completely cleared from the plasma

192
Q

a GFR marker should be…

A

filtered freely, not secreted or reabsorbed

193
Q

an RFP marker should be…

A

filtered and completely secreted

194
Q

what is the filtration fraction

A

the fraction of plasma flowing through the glomeruli that is filtered into the tubules

195
Q

substances reabsorbed in the PT

A 
sugars 
amino acids 
phosphate 
sulphate 
lactate 
salt
196
Q

substances secreted in the PT

A 
H+ neurotransmitters 
bile pigments 
uric acid 
drugs (eg penicillin)
toxins
197
Q

how is sodium transported out of tubular cells

A

NaK pump

one sodium out, one potassium in

198
Q

how is glucose transported into tubular cells

A

sodium dependent glucose transporter

199
Q

how is glucose transported out of the tubular cells

A

facilitated diffusion

200
Q

what is the transport maximum

A

the maximum amount of a substance that can be transported at one time
transport processes for reabsorption/secretion are saturated

201
Q

what is the renal threshold for plasma glucose

A

10-12 mmol/L

202
Q

what is countercurrent flow

A

opposing flow in two limbs

203
Q

what is reabsorbed in the AL of the loop go henle

A

Na
Cl
WATER IMPERMEABLE

204
Q

what is reabsorbed in the DL

A

no NaCl

HIGHLY PERMEABLE TO WATER

205
Q

what is the purpose of countercurrent multiplication

A

to concentrate the medullary interstitial fluid

DERM (5 decks)

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