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6901 > Renal > Flashcards

Renal Flashcards

1
Q

6 hormones secreted by the renal system

A 
Aldosterone
Anti-diuretic hormone
Angiotensin
Atrial Natriuretic Factor
Vitamin D
Erythropoietin
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2
Q

Location on spinal column of kidneys

A

T12 - L3

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3
Q

Location of right vs left kidney

A

Right kidney is slightly lower than the left because of hepatic displacement

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4
Q

Hilus of the kidney

A

Recessed fissure in medial margin of kidney, concaved shape

-Renal artery, renal vein, nerves, lymphatics, and ureters enter/exit the kidney here

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5
Q

Regions of kidney: Outer ___, inner ____

A

Outer cortex
Inner medulla
-Divided into wedges called pyramids
-Pyramid bases are directed toward cortex, apexes converge toward renal pelvis

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6
Q

Path filtrate takes through the nephron

A

Nephron=functional unit of kidney, 1,250,000 of them in each kidney

  • Afferent arteriole
  • Glomerulus - Efferent arteriole
  • Bowmans capsule
  • Proximal convoluted tubule
  • Loop of henle
  • Distal convoluted tubule
  • Collecting duct
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7
Q

Cortical vs juxtamedullary nephrons

A

Cortical: 70-80%
-Have short loop of henle, extend only to superficial regions of medulla, lack a thin ascending limb
Juxtamedullary: 20-30%
-Important in concentrating urine
-Renal corpuscles located near the medulla, loops of henle project deeply into medulla

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8
Q

Blood flow to kidneys (mL/min, % CO)

A

1100-1200 mL/min

20-25% CO

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9
Q

Where blood goes after it leaves the renal vein

A

Inferior vena cava

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10
Q

Renal fraction

A 
Cardiac output that passes through the kidneys
-CO ~5600 mL/min
-RBF ~1200 mL/min
Normal renal fraction = 21%
-Can vary from 12-30%
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11
Q

Regulation of renal blood flow equation

A

=(MAP-VP) x VR
VP=Venous pressure
VR=Vascular resistance
Regulated by:
-Autoregulation: Afferent arteriole vasodilation and myogenic mechanisms
-Neural regulation: SNS innervates afferent and efferent arterioles
-SNS stimulation will decrease RBF

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12
Q

MAP that autoregulation can maintain RBF between

A

50-180 mmHg

-Remains 1200 mL/min to both kidneys

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13
Q

GFR

A

Glomerular filtration rate

  • Quantity of glomerular filtrate formed each minute in the nephrons
  • Most important index of intrinsic renal function
  • 125 mL/min - 180 L/day
  • 99% of this is reabsorbed from the renal tubules
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14
Q

Juxtaglomerular complex

A

Regulates GFR
Distal convoluted tubule
-Lie between afferent and efferent arterioles
-Cells here that come into contact with the arterioles=macula densa
Smooth muscle cells of the afferent and efferent arterioles consist of juxtaglomerular cells
-Contain renin
Structure is anatomically arranged to allow fluid in the distal tubule to alter afferent or efferent arteriolar tone - regulate GFR

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15
Q

SNS stimulation affect on juxtaglomerular cells

A

SNS/decreased Na and Cl delivery to macula densa -> renin release from juxtaglomerular cells

  • Renin -> angiotensinogen from liver -> angiotensin I -> angiotensin II in lung with ACE
  • Angiotensin II = efferent arteriole contriction (vasocontriction in general) = increased pressure in glomerulus = increased GFR
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16
Q

Proximal tubule major function

A

Active transport of Na(Na/K/ATPase)

  • Water, lytes, and organic substances are cotransported with Na
  • Angiotensin II and Norepi will enhance this Na reabsorption
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17
Q

Loop of henle primary function

A

Descending and ascending portions

  • Maintain a hypertonic medullary interstitum
  • Indirectly provide the collecting tubules with the ability to concentrate urine
  • 15-20% of Na is reabsorbed
  • Descending limb: solute and water reabsorption is passive, follows concentration and osmotic gradients
  • Ascending thick segment: Na and Cl absorbed in excess of water
  • Countercurrent mechanism: Establishes a hyperosmotic state - vital for water conservation
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18
Q

Distal convoluted tubule primary function

A

Na reabsorbed under influence of aldosterone
K concentration controlled
-Secreted into lumen in exchange for Na
*Only permeable to water in the presence of ADH

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19
Q

Collecting tubule primary function

A

Acidifying urine (H secretion)
Aldosterone and Na reabsorption
ADH determines permeability of water
-Dehydration: Increased production of ADH
-Adequate hydration: Decreased production of ADH

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20
Q

Juxtaglomerular apparatus primary function

A

Contain renin
Innervated by Beta-1 adrenergic SNS
-Decreased GFR=over absorption of Na and Cl - decreased delivery to macula densa - AA vasodilates - increased RBF

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21
Q

Aldosterone

A
  • Produced: Adrenal cortex
  • Increases Na/H2O reabsorption
  • Regulated: K concentration (strongest trigger) in ECF, renin-angiotensin, ECF Na concentration
  • Target: Distal nephron
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22
Q

ADH

A
  • Synthesized: Hypothalamus
  • Release: Posterior pituitary
  • Regulated: Osmoreceptors near hypothalamus sense ECF concentration, inhibited by stretch atrial barorecptors
  • Target: Distal tubule, collecting ducts, impermeable to water without ADH, with ADH-water is reabsorbed
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23
Q

Renin and Angiotensin

A

Renin released from
-Beta-adrenergic stimulation
-Decreased AA perfusion
-Decreased Na
Acts on hepatic angiotensin - angiotensin II in lungs
-Vasoconstriction
-Stimulates aldosterone release from adrenal cortex

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24
Q

Atrial natriuretic factor

A
  • Produced: Cardiac atria
  • Stimulus: Stretch/distention/increased pressure in atria
  • Effect: Increased Na excretion, urine flow, RBF, GFR
  • Potent diuretic
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25
Q

Erythropoietin

A
  • Created: Kidneys

- Effect: Stimulates RBC production

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26
Q

Prostaglandins

A 
Modulate the renal effects of other hormones, protective vasodilators during periods of hypotension and ischemia
PGE2
-Vasodilator
Thromboxane A2
-Contraction of vascular smooth muscle
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27
Q

Vitamin D

A

-Vital role in calcium metabolism

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28
Q

% that anesthesia can depress renal function

A

30-40%

-Directly correlated with degree of sympathetic block and BP depression, impairment of autoregulation

29
Q

Renal effects in general vs regional anesthesia

A

Both = Reversible decrease in RBF, GFR, urinary flow, Na excretion

  • Usually less pronounced during regional anesthesia
  • Indirect, mediated by autonomic and hormonal responses to surgery
30
Q

Anesthetic drugs ___ renal perfusion, ____ vascular resistance

A

Decrease renal perfusion

Increase vascular resistance

31
Q

Drugs that stimulate catecholamines cause an ___ in renal vascular resistance, vaso____, and ____ RBF

A

Increase in renal vascular resistance
Vasoconstriction
Decreased RBF

32
Q

Inhalation agents ___ renal vascular resistance in response to a ___ SVR

A

Increase renal vascular resistance

Lower SVR

33
Q

Neurologic effects in periop period

A

Increased SNS tone occurs periop from anxiety, pain, light anesthesia, surgical stimulation

  • > Increased renal vascular resistance
  • > Activates hormonal systems -> reduced RBF, GFR, UOP
34
Q

Endocrine stimulation periop

A

Common component of stress response

  • > Increase epi, norepi, renin, angiotensin II, aldosterone, ADH, ACTH, cortisol
  • At least party responsible for transient fluid retention seen postop in many patients
35
Q

Inhalation agent nephrotoxicity

A

Methoxyflurane - old agent no longer used
-Release of inorganic fluoride ions in metabolism = cause
-Fluoride alters renal concentration by interfering with active transport of Na and Cl
-Potent vasodilator, inhibits ADH - interferes with urine concentrating ability
-2-5 days postop pts had high nonconcentrated UOP - fluid/lyte imbalances - death
-AKA Penthrane polyuria
None of the modern agents are nephrotoxic

36
Q

Sevoflurane and renal toxicity

A

5-8% metabolism - metabolites = fluoride and HFIP (1/4th Fl production as methoxyflurane)
-Compound A only fund in animal studies, not humans, FDA recs 1LPM FGF if <1 hour, 2LPM if >1hr

37
Q

Nonoliguric vs oliguric vs anuric AKI

A

Nonoliguric: UOP >400 mL/day
Oliguric: UOP <400 mL/day
Anuric: UOP <100 mL/day

38
Q

How many ICU patients will develop AKI after a major surgical procedure

A

36%

39
Q

Most common cause of ESRD

A

Glomerulonephritis

-Due to deposition of antigen-antibody complex in the glomeruli

40
Q

Diuretics for AKI prevention

A

Increases UOP but doesn’t decrease chronic renal dysfunction or mortality
-Must be balanced with fluid administration to prevent hypotension and hypoperfusion

41
Q

Key approaches to treat AKI

A

Administer volume to achieve euvolemia
Improve CO by afterload reduction
Normalize SVR

42
Q

CKD characteristic

A 
GFR<60 mL/min for >3 months
5 stages...
1: Kidney damage, GFR normal
2: Kidney damage, GFR 60-89
3: GFR 30-59
4: GFR 15-29
5: ESRD, GFR<15
43
Q

Nephron function with aging

A

Normal - nephron function <10% for each decade of life

-Renal insufficiency is common in the geriatric population

44
Q

Most important source of information in preop assessment for renal disease patients

A

Medical history

-History arousing suspicion should lead to a more thorough evaluation of renal function

45
Q

What medication to use if excessive bleeding is present preop for ESRD patients

A

Desmopressin

46
Q

Ideal weight preop for ESRD dialysis patients

A

1-2 kg above “dry weight”

-Dialyze 24 hours or less before surgery

47
Q

Creatinine clearance

A

-Specific test of GFR
-Most reliable assessment tool for renal function
-Measures glomerular ability to excrete creatinine into urine for a given plasma concentration
=(urine creatinine x urine volume) x serum creatinine (24 hour urine specimen needed)
-Normal: 95-150 mL/min

48
Q

Urinalysis tests to look for

A

Specific gravity: renal capacity to excrete concentrated or dilute urine
Urine osmolality: indicative of tubular function
Proteinuria: indicates severe glomerular damage
Urinary pH: ability to acidify urine

49
Q

CKD pharmacological implications (volume of distribution, protein bound drugs, acidosis, metabolites, anema, uremia)

A
  • Larger volume of distribution
  • Highly protein bound drugs will have greater effect
  • Acidosis-more unionized drug available (cross lipid membrane faster)
  • Metabolites can accumulate and become physiologically active
  • Anemia increases CO/delivery to brain
  • Uremia alters integrity of BBB, increased sensitivity
50
Q

CKD effect on ketamine, sodium penthothal, Propofol, benzos, narcotics, inhalation agents, muscle relaxants

A

Ketamine: Metabolites accumulate, may worsen HTN (catecholamine release)
Sodium penthothal: Highly protein bound, exaggerated prolonged effect
Propofol: Hyperdynamic state - increased dose
Benzos: Greater sensitivity if hypo-albuminemic
Narcotics: Increase volume of distribution, exaggerated response, slow elimination half-life
-Morphine: May have prolonged respiratory depression
-Meperidine: Norperidine metabolite, seizures, respiratory depression
-Sufentanil: highly variable clearance and half life
Inhalation agents: Avoid methoxyflurane
Muscle relaxants:
-Succinylcholine: Increased K, increased block (accumulation of metabolites)
-Roc, vec, mivacurium: Block may be prolonged, unpredictable
-Atracurium, cis: Drug of choice, predictable (Hoffman elimination)

51
Q

Acidosis with regional anesthesia

A

Will affect block

  • Faster onset
  • Shorter duration
52
Q

Preop fluid and intraop UOP for CKD

A

Preop hydration with NS: 10-20 mL/kg

0.5-1 mL/kg/hr UOP

53
Q

Loop vs osmotic vs aldosterone antagonist vs thiazide diuretics

A

Loop: Lasix
-Inhibits reabsorption of Na and Cl, augments secretion of K
Osmotic: Mannitol, isosorbide
-Inhibits reabsorption of water and Na, increase osmolarity of blood - increased secretion of water
Aldosterone antagonist: Spironolactone
-Offsets loss of K with thiazide diuretics, watch for high K
Thiazide: Chlorothiazide, hydrochlorothiazide
-Used for essential HTN
-Inhibits reabsorption of Na
-Side effects: Hypokalemia, muscle weakness, potentiation of NDMRs

54
Q

Most common position for urologic procedures

A

Lithotomy

55
Q

Cystoscopy

A

Camera into bladder

-Spinal MAC, MAC, GA

56
Q

Brachytherapy

A

Radioactive implants inserted into tissue

  • To treat ca (prostate esp)
  • Spinal, epidural, GA
57
Q

Extracorporeal shock wave lithotripsy

A

High energy shock waves passed through body to break urinary stones

  • Water immersion vs dry (common dry now)
  • Shock waves sync to R waves of heart (notify surgeon if CV issues)
  • Anesthetic concerns if panc/hepatic damage, plt dysfunction
  • Contraindicated: AAA, pregnancy, morbid obesity
  • MAC, GA
58
Q

Radical prostatectomy

A

Remove prostate gland, bladder neck, seminal vesicles, ampullae of vas deferens, pelvic lymph node dissection

59
Q

Radical retropubic prostatectomy

A

Vertical incision below umbilicus
-High EBL (500) from dorsal vein
-Foley clamped on field, blood can mix with urine b/c bladder is open
Laparoscopic/Robotic
-Extreme Trendelenburg - venous congestion, ventilation difficulty
-Peripheral neuropathy risk
-Arms tucked, 2 PIVs present, possible A-line

60
Q

Radical perineal prostatectomy

A

Extreme lithotomy position - shoulder braces on acromion process - high risk for nerve injury

  • Less EBL than Radical retropubic prostatectomy
  • Bleomycin patients (for ca): At risk for pulmonary insufficiency, oxygen toxicity, fluid overload
61
Q

Radical nephrectomy

A

Excision of peri-nephritic fat and fascia, proximal 2/3 of ureter, para-aortic lymph nodes

  • GA, epidural
  • 2 PIVs, possible A-line
  • Potential for high EBL especially if tumor is well vascularized (involvement with IVC=5-10%)
  • Position: Supine or lateral with bean bag
  • Fluid: NS/LR 6-8 mL/kg/hr, UOP >0.5 mL/kg/hr, use mannitol, lasix, or renal dose dopamine
  • Concerns: Potential for pneumothorax, decreased venous return if pressure on vena cava, increased airway pressures (retraction of diaphragm)
62
Q

Renal transplant patients goal SBP and CVP

A

SBP>100

CVP 10-15

63
Q

Cystectomy

A

Removal of all or part of bladder, simple or radical

  • GA, epidural
  • Many patients are smokers, have underlying renal impairment
64
Q

TURBT

A

Transurethral resection of bladder tumor

  • Cysto with rigid scope
  • GA or spinal
65
Q

TURP

A

Transurethral resection of the prostate

-Spinal preferred - monitor for CNS signs of hyponatremia (TURP syndrome)

66
Q

TURP syndrome

A

Hyponatremia dur to large amounts of irrigation used, venous sinuses are open - systemic absorption of irrigation fluid

  • Spinal anesthesia is less likely to mask symptoms
  • Some irrigations use NaCl and special cautery to avoid this
  • Symptoms: periop or postop, headache, restless, confused, cyanosis, arrhythmias, hypotension, seizures (fluid overload, water intoxication)
  • Treatment: Hypertonic saline, lasix
67
Q

Treatment for hyperkalemia

A 
Calcium chloride
Hyperventilation
Insulin
Glucose
Sodium bicarbonate
68
Q

What patient population should osmotic diuretics not be used in?

A

CHF

-Get pulmonary edema

69
Q

Diamox makes urine ___

A

Alkaline

6901 (9 decks)

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