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The patient (Y2-2) > Renal > Flashcards

Renal Flashcards

1
Q

The kidneys are served by the renal artery and the renal vein. Which serves oxygenated blood and which serves deoxygenated blood?

A

Artery - oxygenated

Vein - deoxygenated

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2
Q

The kidneys lie in the peritoneal cavity with the intestines and the liver. True or false?

A

False - they lie in the back of the abdominal wall

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3
Q

What are the three functions of the kidneys?

A

Homeostasis
Excretion
Endocrine

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4
Q

The kidneys are involved in the production of _________ which is important in the production of RBCs

A

Erythropoietin

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5
Q

Blood flows into the nephron via the efferent arteriole. True or false?

A

False - through the afferent

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6
Q

What is glomerular filtration?

A

The movement of molecules from plasma in glomerulus into Bowman’s space

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7
Q

The afferent arteriole is narrower than the efferent arteriole. True or false?

A

False - efferent is narrower

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8
Q

Plasma filters from glomerulus into Bowman’s space through 3 layers. What are they?

A 
Capillary endothelium
Basement membrane
Capsule cells (podocytes)
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9
Q

What is meant by the glomerular filtration rate?

A

The volume of fluid filtered into Bowman’s capsule per unit time

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10
Q

GFR can determine the stage of chronic kidney disease. True or false?

A

True

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11
Q

What effect does chronic kidney disease have on GFR?

A

As chronic kidney disease worsens, GFR decreases and albuminurea increases

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12
Q

What can be administered IV to measure kidney function?

A

Inulin

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13
Q

Inulin is a polymer of sucrose. True or false?

A

False - polymer of fructose

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14
Q

Inulin is not absorbed nor secreted by the nephron. True or false?

A

True

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15
Q

The amount of inulin that is filtered into the Bowman’s capsule is equal to the amount that is excreted in the urine. True or false?

A

True

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16
Q

Other than inulin, what can be used to measure renal function?

A

Creatinine

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17
Q

Creatinine is produced by muscles. True or false?

A

True

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18
Q

Creatinine is secreted by the nephron. True or false?

A

True

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19
Q

What three paratmeters are needed to measure renal clearance?

A

Rate of urine production
Urine concentration of drug
Plasma concentration of drug

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20
Q

What is renal clearance defined as?

A

The volume of plasma from which a substance is completely removed per unit time

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21
Q

What is ABCG2 also known as?

A

BCRP

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22
Q

What is ABCB1 also known as?

A

P-gp

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23
Q

MRP is an uptake transporter. True or false?

A

False - efflux transporters

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24
Q

Name 3 efflux transporters

A

P-gp
BRCP
MRP

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25
Q

Which uptake transporters does methotrexate bind to?

A

OCT1

OAT1

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26
Q

Which efflux transporters clear methotrexate?

A

MRP2, MRP4 and ABCB1

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27
Q

Pivastatin and rosuvastatin are recognised by which uptake transporter?

A

OAT3

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28
Q

Pivastatin and rosuvastatin are cleared by which efflux transporter?

A

BCRP

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29
Q

Fexofenidine is recognised by which uptake transporter?

A

OAT3

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30
Q

Fexofenidine is effluxed by which transporter?

A

ABCB1

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31
Q

Which uptake transporter does digoxin bind to?

A

OATP

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32
Q

Which transporter is digoxin effluxed by?

A

ABCB1

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33
Q

What is the aim of diabetes treatment?

A

Reduce plasma glucose

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34
Q

How can the amount of glucose in the plasma be reduced?

A

Block the glucose transporter so that glucose reabsorption is reduced and glucose is eliminated in urine instead

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35
Q

Name a SGLT2 inhibitor that is licensed for the treatment of type 2 diabetes

A

Dapagliflozin

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36
Q

70% of filtered Na+ is reabsorbed in the ________ ______

A

proximal tubule

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37
Q

All sodium is reabsorbed early on in the nephron. True or false?

A

False - some of it is reabsorbed later on in the nephron in the collecting ducts

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38
Q

What is the role of the antiporter protein?

A

Na+ reabsorption - entry of Na+is couple to H+

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39
Q

How do the kidneys help in regulating the acid-base balance?

A

They secrete H+ which passes out in the urine and produce HCO3- which can be used as a buffer

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40
Q

Which other organ does the kidney work with in order to regulate the acid-base balance in homeostasis?

A

Lungs

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41
Q

What happens in respiratory acidosis?

A

There is a build up of H+ in the protons and so blood through the lungs is compromised as a result of the fibrous mass. The kidneys correct this disorder by increasing the excretion of H+ secretion

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42
Q

Which hormone regulates Na+ ions?

A

aldosterone

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43
Q

Where is aldosterone produced?

A

In the adrenal cortex

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44
Q

What effects does aldosterone have on Na+?

A

When aldosterone is secreted, it tells cells in the collecting ducts to increase the number of Na+ channels in the apical membrane
It also tells cells to increase the number of pumps in the basolateral membrane

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45
Q

Which system stimulates the secretion of aldosterone?

A

Renin-angiotensin system

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46
Q

What happens in the renin-angiotensin system?

A

Low levels of Na+ are sensed by the kidney juxtaglomerular cells. These produce renin
Angiotensinogen is secreted by the liver in low levels. Renin converts angiotenisinogen into angiotensin I.
Angiotensin I is converted to angiotensin II by ACE which is secreted by kidney and lung capillary cells
Angiotensin II circulates in the body, gets to the adrenal cortex and stimulates it to produce aldosterone

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47
Q

What are ACE inhibitors indicated for?

A

Hypertension

Heart failure

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48
Q

Name to diuretics

A

Spironolactone

Amiloride

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49
Q

What will a patient with excessive aldosterone experience?

A

Increased Na+ reabsorption, increased water reabsorption and this is associated with congestive heart failure

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50
Q

Which diuretic is a aldosterone analogue?

A

Spironolactone

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51
Q

What is the mechanism of action of spironolactone?

A

Binds to the aldosterone receptor, inhibiting the binding of aldosterone and so it can’t tell cells to increase Na+ channels or pumps and so water and Na+ pass out of the urine as a result

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52
Q

What is the mechanism of action of amiloride?

A

Binds to Na+ channels on the apical membrane and so blocks Na+ entry into the cell. This results in Na+ and water remaining in the tubular fluid and passing out in urine

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53
Q

Where in the kidney do diuretics act?

A

cortical duct

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54
Q

Aldosterone binds to cells in the cortical collecting duct. True or false?

A

True

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55
Q

What effect does hypertension have on nephrons?

A

They are reduced

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56
Q

There are gap junctions between epithelial cells of the proximal convoluted tubule. True or false?

A

False - tight junctions

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57
Q

How much Na+ reabsorption is the PCT responsible for?

A

60-70%

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58
Q

What is the role of the counter current multiplier in the descending loop of Henle?

A

It is a way of concentrating interstitial fluid in the renal medulla i.e. concentration of the interstitial fluid increases as LoH descends

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59
Q

Why is it important that the concentration of interstitial fluid is hypertonic outside the filtrate?

A

So water can pass out into the blood

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60
Q

Are cells in the descending loop of Henle permeable to water?

A

Yes - water diffuses out of the lumen down a conc gradient

61
Q

Are cells in the thick ascending loop of Henle permeable to water?

A

They have low permeability to water

62
Q

How much Na+ is reabsorbed in the ascending loop of Henle?

A

20-30%

63
Q

How does Na+ move in the ascending loop of Henle?

A

Na+ is pumped out of the cell via the basolateral membrane Na/K pump - this creates a gradient for Na+ to cross the apical membrane via the Na/K/Cl transporter

64
Q

Is the distal convoluted tubule permeable to water?

A

No - impermeable to water

65
Q

Does Na+ reabsorption take place in the distal tubule?

A

Yes - reabsorbed down a conc gradient

66
Q

How is water reaborbed in the collecting tubule?

A

Via aquaporin channels

67
Q

How do aquaporin channels function?

A

they are stored in vesicles - ADH binding to vasopressin receptors causes their insertion into the apical membrane. They can remove as much as 15% of filtered water, making urine considerably hypertonic to plasma

68
Q

What mediates Na+ reabsorption in the collecting tubule?

A

Aldosterone

69
Q

All diuretics are secreted by cells of the PCT into the lumen. True or false?

A

False - most but not spironolactone

70
Q

Loop diuretics are powerful. Roughly how much of filtered Na+ is excreted?

A

15-25%

71
Q

How do loop diuretics work?

A

They inhibit the Na/K/Cl carrier in the thick ascending limb of loh

72
Q

What type of diuretic is furosemide?

A

Loop diuretic

73
Q

Is the Na+/H+ exchanger affected in loop diuretics?

A

No - so Na+ drives H+ excretion

74
Q

There is an increase in magnesium and calcium excretion as a result of loop diuretics. True or false?

A

True

75
Q

What are the indications for loop diuretics?

A 
acute pulmonary oedema 
liver cirrhosis and ascites 
CHF
Renal failure
Hypertension
Hypercalcaemia
76
Q

What are the side effects of loop diuretics?

A 
Hypotension
Hypokalaemia 
Metabolic alkalosis
Gout 
Hearing loss
77
Q

Where is the site of action of thiazide diuretics?

A

Distal tubule

78
Q

What is the moa of thiazide diuretics?

A

Inhibit the Na+/Cl- cotransporter

79
Q

What is the problem with thiazide diuretics?

A

Reduced blood volume leads to increase in renin release which in turn increases AngI and AngII production which are vasoconstrictors - increased BP - limiting the hypotensive effect during chronic dosing

80
Q

What are the indications of thiazide diuretics?

A

Hypertension
Mild-moderate heart failure
Oedema
Nephrogenic diabetes insipidus

81
Q

What are the side effects of thiazide diuretics?

A

Increased urinary frequency
Erectile dysfunction
Hypokalaemia
Impaired glucose tolerance

82
Q

Thiazide diuretics are only effective orally. True or false?

A

True

83
Q

Chlotalidone and metolazone are which types of diuretics?

A

Thiazide

84
Q

Name a thiazide diuretic

A

Indapamide

85
Q

What foods/drink increase K+?

A

Bananas
Instant coffee
Fruit juice

86
Q

Where is the site of action of K sparing diuretics?

A

Collecting tubule

87
Q

Name a K sparing diuretic

A

Spironolactone

Eplerenone

88
Q

What are the indications for spironolactone

A

Ascites
Oedema
Severe heart failure

89
Q

What is the indication for epleronone?

A

Adjunct in patients with LV failure following IM

90
Q

What are the side effects of K sparing diuretics?

A

hyperkalaemia
GI upset
Gynaecomastia

91
Q

What is the moa of triamterene and amiloride?

A

Inhibit Na+ reabsorption by blocking luminal Na+ channels in collecting tubules

92
Q

What are the indications for amilodride and triamterene?

A

Adjunct to loop/thiazide for hypertension and CHF

93
Q

Which drugs are not safe to use in patients with renal impairment or drugs which increase K?

A

Amiloride and triamterene

94
Q

Amiloride has a slower onset than triamterene and is less well absorbed. True or false?

A

True

95
Q

Amiloride is excreted unchanged in the urine. True or false?

A

True

96
Q

Name an osmotic diuretic.

A

Mannitol

97
Q

What are the indications for mannitol?

A

Cerebral oedema
Raised intra-occular pressure
Acute renal failure

98
Q

The kidneys regulate red blood cell production. True or false?

A

True

99
Q

The kidneys regulate bone-mineral metabolism. True or false?

A

True

100
Q

What is the definition of CKD?

A

Kidney damage for over 3 months as evidenced by structural abnormalities with normal or decreased GFR (>60ml/min/1.73)
GFR < 60ml/min/1.73 with or without kidney damage for over 3 months

101
Q

How is CKD diagnosed?

A

Blood/urine tests or imaging

102
Q

All CKD progresses to end-stage kidney disease eventually. True or false?

A

False

103
Q

What does a GFR <15ml/min/1.73 indicate?

A

Kidney failure

104
Q

What are the markers of kidney disease?

A 
Albuminuria
Urine sediment abnormalities 
Electrolyte and other abnormalities due to tubular disorders
Abnormal histology
History of kidney transplantation
Structural abnormalities
105
Q

What are the advantages of using serum creatinine as a marker of kidney disease?

A

It is produced at an almost constant rate
Readily available to most labs
Easy to do - single blood sample

106
Q

What are the disadvantages of serum creatinine?

A

It is proportional to muscle mass so need to know age, sex, body size, ethnicity, gender etc.
Value usually used in equations to estimualt GFR

107
Q

What is the best measure of overall kidney function?

A

GFR

108
Q

What is the normal GFR value?

A

~100ml/min - works like a %

109
Q

What correction factor needs to be applied when calculating creatinine based GFR?

A

1.159 for patients of African-caribbean or African family origin

110
Q

How does a decreased muscle mass influence GFR?

A

It will result in overestimation

111
Q

How does an increased muscle mass influence GFR?

A

It will lead to an underestimation

112
Q

Which type of GFR test is cautioned with uncontrolled thyroid disease?

A

Cystatin C-based GFR

113
Q

What are some risk factors of CKD?

A

Hypertension
Diabetes
AKI
Cardiovascular disease

114
Q

Proteinuria is a non-modifiable risk factor of CKD. True or false?

A

False - modifiable

115
Q

Dyslipidaemia is a modifiable risk factor of CKD. True or false?

A

True

116
Q

What are some causes of CKD?

A 
Diabetes
Pyelonephritis 
Glomerulonephritis
Polycystic kidney disease
Kidney stones
117
Q

What are some early interventions that could be taken to delay or prevent end stage renal disease?

A

Reduce proteinuria
BP control
Glycaemic control for diabetes

118
Q

What should the BP target be for patients with renal disease, diabetes or conditions that affect the heart and circulation?

A

130/80

119
Q

What complications could arise as a result of CKD?

A

Renal anaemia
Mineral bone disease
Acidosis
CVD

120
Q

Erythropoiesis stimulating agents should be used in patients with anaemia of CKD to correct levels of hb. True or false?

A

False - not recommended

121
Q

What are the causes of CKD anaemia?

A

Uraemia increases the risk of GI bleeding
N+V reduces risk of appetite
Shortened life span of RBCs

122
Q

What is the target Hb level for adults and children over 2 in CKD anaemia?

A

100-120g/l

123
Q

What is the target Hb level for children under 2 in CKD?

A

95-115g/l

124
Q

When should phosphate binders be taken for CKD patients with high phosphate?

A

Immediately before or with meals

125
Q

What causes pruritis in CKD patients?

A

High phosphate levels and/or uraemia

126
Q

How is pruritis in CKD treated?

A

Low phosphate diet, phosphate binders. Symptoms can be controlled using antihistamines

127
Q

How can acidosis as a result of CKD be corrected?

A

Oral sodium bicarbonate

128
Q

What causes nausea in CKD and how is it treated?

A

Build up of toxins - can be treated using anti-emetics e.g. metaclopramide

129
Q

Which class of diuretics should be avoided in moderate to severe renal impairment (eGFR <20mls/min)?

A

Thiazide

130
Q

AKI is irreversible. True or false?

A

False - frequently reversible

131
Q

What are the risk factors for AKI?

A 
Hypovolaemia 
Hypotension 
Diabetes 
Liver disease 
Heart failure
132
Q

How is AKI detected?

A

A rise in creatinine of 26 micromols/l or more within 48 hrs

A fall in urine output to less than 0.5ml/kg/hr for more than 6 hrs in adults and more than 8 hrs in children

133
Q

What causes AKI?

A

Majority is pre-renal due to reduced renal perfusion i.e. dehydration, hypotension, sepsis
Post-renal - prostate enlargement
Renal - NSAIDs, ACEI

134
Q

What are the two types of dialysis?

A

Haemodialysis

Peritoneal dialysis

135
Q

What is the advantage of HD?

A

good removal of electrolytes

136
Q

What are some disadvantages of HD?

A 
Anaemia 
Hypotension 
Expense 
Pain 
Pruritis 
Access is surgically induced
137
Q

What are the advantages of PD?

A

Fluid balance less tight

Renal function declines less rapidly

138
Q

What are the disadvantages of PD?

A

Constipation
Infections
Electrolyte removal not as good

139
Q

What causes hypotension as a result of dialysis?

A

Too much fluid being removed too quickly

140
Q

Kidney transplantation is cheaper than dialysis. True or false?

A

True

141
Q

What are the common combinations of immunosuppressive agents in AKI?

A

Ciclosporin/tacrolimus +/- prednisolone
Ciclosporin/tacrolimus +/i prednisolone +/- azathioprine
Prednisolone+/- azathioprine

142
Q

The therapeutic range of ciclosporin, tacrolimus and sirolimus changes over time since transplant. True or false?

A

True

143
Q

What drugs increase ciclosporin/tacrolimus levels?

A

Amiodarone

ABs (e.g. erythromycin, clarithromycin, ketaconazole), diltiazem

144
Q

What drugs decrease ciclosporin/tacrolimus levels?

A 
Rifampicin 
Carbamazepine 
Phenytoin 
Phenobarbitone 
St Johns Wort
145
Q

What affect does oedema and ascites have on volume of distribution?

A

Increase vd of highly water soluble drugs or protein bound drugs resulting in lower plasma concentrations

146
Q

What 3 things does renal excretion depend on?

A

GF
Renal tubular secretion
Re-absorption

147
Q

What is the first choice analgesic in kidney disease?

A

Paracetamol

148
Q

Morphine metabolites accumulate in renal failure. Name some alternative opioids

A

Oxycodone
Fentanyl
(not codeine as that is metabolised to morphine)

The patient (Y2-2) (8 decks)

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