RENAL Flashcards
(205 cards)
1
Q
pre-renal causes of AKI
A
reduced renal perfusion (fluid depletion/dehydration, sepsis, renal artery obstruction, reduced cardiac output)
2
Q
post-renal causes of AKI
A
stones, tumours, BPH, obstruction in bladder/ureters/urethra
3
Q
intra-renal causes of AKI
A
acute tubular necrosis, interstitial nephritis, vasculitis, GN, renal artery/vein obstruction
4
Q
sings of AKI
A
hyperkalaemia/hypokalaemia raised creatinine raised urea acidosis reduced/no urine output
5
Q
examples of fluid shift
A
ascites, effusions, capillary leak states (sepsis/burns)
6
Q
causes of negative fluid balance
A
decreased input
increased output
fluid shift
7
Q
renin is secreted in response to what
A
reduction in glomerular filtration rate
8
Q
how is a reduction in the GFR detected
A
stretch receptors in the macula dense cells of the juxtaglomerular apparatus are stimulated
9
Q
action of renin
A
angiotensinogen to angiotensin I
10
Q
which enzyme converts angiotensin I to angiotensin II
A
ACE
11
Q
what stimulates release of aldosterone
A
renin
12
Q
effect of aldosterone release
A
increased sodium reabsorption in the DCT
increased excretion of potassium
13
Q
what is renal artery stenosis
A
narrowing of the renal artery lumen
14
Q
chronic elevation of angiotensin II results in what
A
cardiac and vascular hypertrophy
15
Q
what does atrial natriuretic factor detect
A
atrial filling
16
Q
what stimulates release of ANP
A
increased volume (increased atrial filling)
17
Q
what does ANP do
A
inhibits sodium reabsorption in the DCT (opposes aldosterone)
18
Q
mechanism of action of ACEIs
A
inhibits the formation of angiotensin II leading t vasodilatation
19
Q
examples of ACEI
A
rampiril, lisonopril
20
Q
mechanism of action of ARBs
A
block angiotensin II receptors on blood vessels/tissues
21
Q
examples of ARBs
A
losartan
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
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
24
Q
example of a1 receptor blocker
A
tamulosin
25
nephrotoxic side effects of gentamicin
acute tubular necrosis
26
nephrotoxic side effects of vancomycin
acute interstitial nephritis
27
nephrotoxic side effects of ACEIs
reversible acute renal failure (HTN/CHF)
28
nephrotoxic side effects of diuretics
reduced GFR
hypokalaemia nephropathy
polyuria
interstitial nephritis
29
nephrotoxic side effects of NSAIDs
AKI caused by sodium and water retention, reducing renal blood flow and direct kidney injury
30
what is the 'triple whammy' effect
the significant increase in harm that may result from the combined use of NSAIDs, ACEIs/ARBs and diuretics in high-risk individuals.
31
mechanism of action of the 'triple whammy' effect
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
32
what is the definition of CKD
gradual loss of kidney function due to abnormal function or structure
33
what is the best measure of overall kidney function
GFR
34
what factors are taken into account when calculating eGFR
serum creatinine, age, gender, race
35
what advice should be given to patients before eGFR testing
avoid eating meat for 12 hours before
36
GFR for CKD stage 1
>90
37
GFR for CKD stage 2
60-89
38
GFR for CKD stage 3
30-59
39
GFR for CKD stage 4
15-29
40
GFR for CKD stage 5
<15
41
effect of ageing on GFR
decreases with age
42
NICE guidance for patients over 70 with reduced GFR
stable GFR >45 is unlikely to be associated with CKD-related complications
43
GFR for CKD stage 3A and 3B
3A 45-59
| 3B 30-44
44
what does the suffix P mean in relation to CKD staging
proteinuria
45
common causes of CKD
diabetes, GN, pyelonephritis, renal vascular disease, polycystic kidney disease, hypertension
46
patients at higher risk of developing CKD
```
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
```
47
common nephrotoxic drugs
NSAIDs
lithium
diuretics
ACEIs
48
lifestyle measures for management of CKD 1,2,3
```
smoking cessation
weight loss
regular exercise and a healthy diet
sensible alcohol consumption
low salt
```
49
what is classed as progressive CKD
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
50
how often should BP be measured in patients with CKD
at least once a year
51
BP target s for patients with CKD
120-139 mmHg systolic and <90 mmHg diastolic UNLESS proteinuria/diabetic with microalbuminuria 120-129 mmHg systolic and <80 mmHg diastolic
52
recommended lab testing for CKD stage 1/2
eGFR, PCR/ACR yearly
53
recommended lab testing for CKD stage 3
eGFR, PCR/ACR, Hb, K+, Ca2+, phosphate 6 monthly (12 monthly if stable)
54
recommended lab testing for CKD stage 4
eGFR, PCR/ACR, Hb, K+, Ca2+, phosphate, HCO3, PTH 3 monthly
55
recommended lab testing for CKD stage 5
eGFR, PCR/ACR, Hb, K+, Ca2+, phosphate, HCO3, PTH 6 weekly
56
first line management of HTN (protein/microalbuminuria) in CKD
ACEIs (or ARBs)
57
when should ACEIs be reduced in dose or stopped
if there is more than a 25% fall in eGFR from the pre-ACEI value
58
indications for referral to nephrologist in CKD
acute renal failure
malignant hypertension
hyperkalaemia (>7 mmol/L)
nephrotic syndrome
59
what is renal bone disease
CKD is associated with elevated PTH, in association with low Ca and high phosphate, and inadequate renal vitamin D production
60
what type of anaemia is commonly associated with CKD
normochromic normocytic anaemia
61
what causes anaemia in CKD
inadequate production of erythropoietin
62
risk factors for urinary incontinence
```
female sex
pregnancy
vaginal delivery
pelvic surgery
pelvic organ prolapse
raised IAP (chronic constipation, lung disease)
obesity
menopause
caffeine
```
63
incontinence may be caused by
neurological dysfunction
abnormalities of detrusor function
abnormalities of the sphincter apparatus (including surrounding pelvic floor muscles and tissue)
anatomical abnormalities
64
four main types of incontinence
stress
urge
mixed
overflow
65
what is stress incontinence
leakage of urine caused by effort or exertion or on coughing/sneezing
66
causes of stress incontinence
problem with the sphincter apparatus
| neurological problem
67
what causes urge incontinence
overactivity of the detrusor muscle
68
what is urge incontinence
uncontrollable leaking of urine preceded by or accompanied by a sudden urge to void
69
what is overflow incontinence
large volume chronic retention due to bladder outflow obstruction resulting in leaking when the bladder can hold no more urine
70
what causes overflow incontinence
prostatic enlargement
| bladder obstruction
71
complications of overflow incontinence
associated with increased risk of renal failure due to vesicouteric incompetence and hydrostatic pressure on the renal system
72
triggers for stress incontinence
coughing, sneezing, exercise, lifting or rising from sitting
73
tiggers for urge incontinence
running taps
| cold weather
74
examination of incontinence
abdominal exam
PR (men)
pelvic (women)
neurological
75
investigations of incontinence
bladder diary for three days
urine dip
bladder scan
76
management of stress incontinence
pelvic floor exercises
| recommend weight loss
77
management of urge incontinence
```
bladder training (6 weeks)
oxybutynin if ineffective
intravaginal oestrogen if atrophy
recommend decreased caffeine intake and weight loss
```
78
urgent referral criteria for incontinence
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
79
routine referral for incontinence
prolapse of the vagina that is symptomatic and visible
| patients with a palpable bladder after voidinh/high post-void volume
80
consider referral for incontinence
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
81
surgical management of stress incontinence
mid-urethral tapes such as tension/free vaginal tapes or transobturator tapes
82
secondary care management of urge incontinence
botox injections
| sacral nerve stimulator
83
management of post-prostatectomy incontinence
pelvic floor exercises
84
management of outflow incontinence
alpha blockers
| 5a-reductase inhibitors
85
action of 5a-reductase inhibitors
inhibit the enzyme responsible for converting testosterone to dihydrotestosterone (important in development of BPH)
slows progression of BPH
86
mechanism of action of a-blockers
relax the smooth muscle of the bladder neck, aiding non-obstructive voiding
87
reversible causes of UI in older people
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
what are LUTS
lower urinary tract symptoms
89
symptoms of BPH
```
urinary frequency
nocturia
urgency
poor flow
incomplete bladder emptying
```
90
differential diagnosis of BPH
```
bladder neck obstruction
urethral stricture
carcinoma in situ of the bladder
Parkinson's disease
cauda equina lesions
nocturnal polyuria
DM
```
91
examination of BPH
PR
92
likelihood of prostate cancer with a raised PSA
20-25%
93
investigation of BPH
PSA
uroflowmetry
measurement of post-ovoidal residual volume
94
upper urinary tract
kidneys
| ureters
95
lower urinary tract
bladder
| urethra
96
what are the 5 layers anterior to the kidney
```
renal capsule
perinephric fat
renal (deep) fascia
paranephric fat
visceral peritoneum
```
97
muscles of the posterior abdominal wall
psoas major
| quadrates lumborum
98
vertebral level of the kidneys
left kidney T12-L2
| right kidney L1-L3
99
what is the clinical relevance of the hepatorenal recess
the most dependent part of the greater sac - fluid more likely to collect there in the supine position
100
the right kidney is posterior to
liver
duodenum
ascending colon
right colic flexure
101
the left kidney is posterior to
stomach
tail of pancreas
hilum of spleen
splenic vessels
102
lymph from the kidneys drains where
lumbar nodes
103
lymph from the ureters drains where
lumbar and iliac nodes
104
what is the ureteric blood supply
```
branches from;
renal artery
abdominal aorta
common iliac
internal iliac
vesical artery
```
105
parts of a nephron
```
glomerulus
bowman's capsule
PCT
loop of henle
DCT
collecting duct
```
106
how does urine drain from the kidney
```
collecting ducts
minor calyx
major calyx
renal pelvis
ureter
```
107
anatomical sites of ureteric constriction
pelviureteric junction
crossing of the common iliac
vesicoureteric junction
108
what is hydronephrosis
urine back pressure into the calyces compressed the nephrons within the medullary pyramids leading to renal failure
109
where is the perineum
between the pelvic floor and skin
110
what makes up the three points of the trigone
2 ureteric orifices
| internal urethral orifice
111
which muscle makes up the majority of the bladder wall
detrusor muscle
112
2 routes for catheterisation
urethral
| suprapubic
113
what is contained in the spermatic cord
```
testicular artery
testicular vein
vas deferencs
lymphatic vessels
nerves
```
114
the testis sit within a sac called the
tunic vaginalis
115
what is a hyprocoele
excess fluid in the tunica vaginalis
116
what are the three cylinders of erectile tissue in the penis called
right and left corpus cavernosum
| corpus spongiosum
117
blood supply to the penis
deep arteries of the penis (branches of the internal pudendal artery from internal iliac)
118
blood supply to the scrotum
internal pudendal and branches from the external iliac
119
lymph form the scrotum and penis is drained where
superficial inguinal nodes
120
lymph from the testis drains where
to the lumbar nodes
121
what are the specialised epithelium cells that overlie the glomerular capillaries called
podocytes
122
which two cell layers separate the blood from the glomerular filtrate
capillary endothelium
| podocytes
123
what lies between the capillary endothelium and the podocyte epithelium
basal lamina
124
what is the function of the mesangial cells
support
| removal of debris
125
what is the thick ascending limb of the loop of henle lined by
simple cuboidal epithelial cells with abundant mitochondria
| extensive brush border
126
cells of the juxtaglomerular apparatus
macula densa
juxtaglomerular cells
extraglomerular mesangial cells (or laces cells)
127
the majority of the conducting parts of the urinary tract are lined by
transitional epithelium (urothelium)
128
what cells make up the transitional epithelium
umbrella (surface) cells
129
2 ways the transitional epithelium is specialised to its function
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
types of epithelium in the female urethra
transitional
| stratified squamous near termination
131
types of epithelium in the male urethra
transitional
stratified columnar after prostate through the penis
stratified squamous at the tip of the penis
132
what is osmolarity
concentration of osmotically active particles present in a solution
133
which two factors influence the osmolarity of a solution
molar concentration
| number of osmotically active particles present
134
what is osmolarity of body fluids
300 mosmol/L
135
what is the tonicity of a solution
the effect a solution has on cell volume
136
2 major fluid compartments
ICF
| ECF
137
the main ions in the ECF are
Na
Cl
HCO3
138
the main ions in the ICF are
K
Mg
-ve charge proteins
139
juxtamedullary vs cortical nephrons
juxtamedullary are less numerous, travel deeper into the medulla and have a vasa recta that follows the loop of Henle
140
what are the three renal processes required to produce and concentrate urine
glomerular filtration
tubular reabsorption
tubular secretion
141
rate of excretion =
rate of filtration + rate of secretion - rate of reabsorption
142
rate of filtration =
concentration in plasma x GFR
143
rate of excretion =
concentration in urine x urine flow rate
144
rate of reabsorption =
rate of filtration - rate of excretion
145
rate of secretion =
rate of excretion - rate of filtration
146
how do sympathetic nerves leave the spinal cord
cranial nerves
| spinal nerves T1-L2 (thoracolumbar outflow)
147
what do sympathetic nerves innervate
smooth muscle
| glands
148
how do sympathetic nerves get from the CNS to the kidneys, ureters and bladder
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
how do parasympathetic nerves leave the CNS
within 4 cranial nerves (II, VII, IX, X) and sacral spinal nerves
(craniosacral outflow)
150
how do parasympathetic nerve fibres get from the CNS to the kidney, ureters and bladder
kidneys and ureters - CNX
| bladder - pelvic splanchnic nerves
151
what types of nerve innervate the kidneys, ureters and bladder
sympathetic
parasympathetic
visceral afferents
(distal urethra and sphincter somatic motor)
152
where is pain from the kidney normally felt
loin
153
where is renal colic normally felt
loin to groin
154
where is pain from the bladder felt
suprapubic
155
where is pain from the perineal urethra felt
perineum (localised)
156
how do visceral afferent get from the kidneys to the CNS
run alongside sympathetic fibres back to the spinal cord
| enter between T11 and L1
157
how do visceral afferent nerve fibres get from the ureters to the CNS
run alongside sympathetic fibres
| enter between T11 and L2
158
how do visceral afferent nerve fibres get from the bladder to the CNS
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
how do visceral afferent and somatic sensory nerve fibres get from the urethra to the CNS
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
how do pain fibres get from the testis to the CNS
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
which spinal cord levels are most important in control of micturition
S2-4
162
femoral nerve innervates which compartment of the thigh
anterior
163
obturator nerve innervates which compartment of the thigh
medial
164
sciatic nerve innervates which compartment of the thigh
posterior
165
superficial fibular innervates which compartment of the leg
lateral
166
deep fibular innervates which compartment of the leg
anterior
167
tibial nerve supplies which compartment of the leg
posterior
168
three physical barriers to glomerular filtration
```
glomerular capillary endothelium
basement membrane (basal lamina)
slit processes of podocytes in glomerular epithelium
```
169
does the glomerular basement membrane have a charge
negatively charged
170
forces that comprise the net filtration pressure
glomerular capillary blood pressure
bowman's capsule hydrostatic pressure
capillary oncotic pressure
bowman's capsule onctoic pressure
171
what is normal GFR
125 ml/min
172
what is the major determinant of GFR
glomerular capillary blood pressure
173
extrinsic control of GFR
sympathetic control via baroreceptor reflex
174
intrinsic control of GFR
myogenic mechanism
| tubuloglomerular feedback mechanism
175
effect of vasoconstriction of the afferent arteriole on GFR
decreases blood flow > decreased net filtration pressure > decreases GFR
176
effect of vasodilation of the afferent arteriole on GFR
increases blood flow > increases net filtration pressure > increases GFR
177
do changes in systemic arterial pressure result in changes in GFR
not necessarily
RBF and GFR are protected from changes in MABP over wide ranges
GFR stays quite constant unless at extremes
178
myogenic auto regulation of GFR
if vascular smooth muscle is stretched (increased BP), it contracts thus constricting the arteriole
179
tubuloglomerular feedback auto regulation of GFR
involved the juxtaglomerular apparatus
| if GFR rises, more NaCl flows through the tubule leading to constriction of afferent arterioles
180
effect of an increased bowman's capsule fluid pressure on GFR
decreased GFR
181
effect of increased capillary oncotic pressure on GFR
decreased GFR
182
effect of decreased capillary oncotic pressure on GFR
increased GFR
183
pressures opposing/favouring filtration
favouring - glomerular capillary fluid pressure, bowman's caplsue oncotic pressure
opposing - bowman's capsule fluid pressure, capillary oncotic pressure
184
name a substance that is filtered, completely reabsorbed and not secreted
glucose
185
name a substance that is filtered, not reabsorbed and not secreted
inulin
186
name a substance that is filtered, partly reabsorbed and not secreted
urea
187
name a substance that is filtered, secreted and not reabsorbed
H+
188
clearance < GFR
substance is reabsorbed
189
clearance = GFR
substance is neither reabsorbed nor secreted
190
clearance > GFR
substance is secreted
191
why is PAH used to calculate renal plasma flow
it if filtered, secreted and not reabsorbed ie it is completely cleared from the plasma
192
a GFR marker should be...
filtered freely, not secreted or reabsorbed
193
an RFP marker should be...
filtered and completely secreted
194
what is the filtration fraction
the fraction of plasma flowing through the glomeruli that is filtered into the tubules
195
substances reabsorbed in the PT
```
sugars
amino acids
phosphate
sulphate
lactate
salt
```
196
substances secreted in the PT
```
H+ neurotransmitters
bile pigments
uric acid
drugs (eg penicillin)
toxins
```
197
how is sodium transported out of tubular cells
NaK pump
| one sodium out, one potassium in
198
how is glucose transported into tubular cells
sodium dependent glucose transporter
199
how is glucose transported out of the tubular cells
facilitated diffusion
200
what is the transport maximum
the maximum amount of a substance that can be transported at one time
transport processes for reabsorption/secretion are saturated
201
what is the renal threshold for plasma glucose
10-12 mmol/L
202
what is countercurrent flow
opposing flow in two limbs
203
what is reabsorbed in the AL of the loop go henle
Na
Cl
WATER IMPERMEABLE
204
what is reabsorbed in the DL
no NaCl
| HIGHLY PERMEABLE TO WATER
205
what is the purpose of countercurrent multiplication
to concentrate the medullary interstitial fluid
