Renal Disease-ALL Flashcards
1
Q
Functional unit of the kidney
A
Nephron
2
Q
Functional Unit of Kidney: Nephron
Includes 3 components:
A
- Glomerulus
- Renal tubules
- Collecting duct
3
Q
Kidney Functions
KNOW BOLD!!!
A
Removes metabolic waste products and excess water FROM the body***
- Excretes metabolic wastes and foreign chemicals
- Gluconeogenesis* in times of fasting*
- Acid-base balance
- Water and electrolyte balances
- Arterial blood pressure
- Secretion, metabolism, excretion of hormones
- Regulation body fluid osmolality and electrolyte conc.
4
Q
Pathogenesis of Kidney Disease
DM and renal tissue damage?
A
DM→ HypERglycemia→ Renal tissue damage***
5
Q
Pathogenesis of Kidney Disease
Angiotensin II NORMAL function?
A
- Vasoconstriction of arterioles and arteries
-
*Must keep pressure adequate for filtration of blood
- AKA→ manages blood pressure for adequate filtration***
6
Q
Angiotensin II attracts __________ and this changes structure of the glomerulus in kidney*
aka NOT helpful in kidney disease!
A
Attracts inflammatory cells!
Cascade→
- Cytokines, growth factors released
- Changes structure of glomerulus
-
=> REDUCED surface area for filtration***
- SO…we don’t want TOO MUCH angiotensin II***
NOTE: this is ALL due to the inflammation!
7
Q
Renal Disease
Initial Sx’s
A
Anorexia, malaise, pruritus (itchy), dry skin, wt. loss
NOTE: Sx’s may NOT appear until kidney function <1/10 normal***
8
Q
Renal Disease Sx’s
W/ Progression of Dis.
A
drowsy/confusion, change skin pigment, excessive thirst, insomnia, edema, peripheral neuropathy (notice trend, LOTS of things can cause this!!! remember this is a circulation/filtration problem so makes sense!!!)
9
Q
Stages of Chronic Kidney Disease
NOTE: happens slow, 5 stages. In ea, kidneys don’t work as well as the stage before. W/ tx and lifestyle changes, YOU CAN help slow or stop kidney dis. from getting worse!
A
-
Stage 1→ Kidney damage w/ normal kidney function
- GFR= 90 or higher
-
Stage 2→ Kidney damage w/ mild loss of kidney function
- GFR= 89-60
-
Stage 3a→ Mild-Moderate loss of kidney function
- GFR= 59-45
-
Stage 3b→ Mod-Severe loss of kidney function
- GFR= 44-30
-
Stage 4→ Severe loss of kidney function
- GFR= 29-15
-
Stage 5→ Kidney failure*
- GFR= LESS THAN 15*
10
Q
Stage 1 Kidney Disease
A
Kidney damage w/ normal function
GFR = 90-100
11
Q
Stage 2 Kidney Disease
A
Kidney damage w/ mild loss of kidney function
GFR= 89-60
12
Q
Stage 3a Kidney Disease
A
Mild-Moderate loss of kidney function
GFR= 59-45
13
Q
Stage 3b Kidney Disease
A
Mod-Severe loss of kidney function
GFR= 44-30
14
Q
Stage 4 Kidney Disease
A
Severe loss of kidney function
GFR= 29-15
15
Q
Stage 5 Kidney Disease
A
Kidney failure
GFR= Less than 15*
16
Q
What does GFR # tell you?
A
HOW much kidney function you have. As kidney disease gets WORSE, GFR # goes DOWN***
17
Q
Chronic Kidney Disease
READ THIS RESOURCE!!!!
A
USE!!!!!!
18
Q
Chronic Kidney Disease (CKD)
Most COMMONLY caused by:
A
DM and HTN
19
Q
CKD aka
A
End Stage Renal Disease (ESRD) → Stage 5*
20
Q
CKD
End-Stage Renal Disease (ESRD)→ Stage 5
A
- FINAL stage of CKD
- <10% kidney function
- REQUIRES dialysis or transplant*
-
HIGH mortality rate
- 65yrs on dialysis== 7x risk of death*
- 60yrs starting dialysis== life expect. 5 yrs (normal=20)
21
Q
CKD aka ______ aka ______
A
End-stage renal disease aka Stage 5
22
Q
CKD
Risk factors, Sx’s to consider w/ PT
A
-
Risk factors:
- hereditary defects of kidneys, UTI, age, excess use analgesics
-
Sx’s of renal failure to consider w/ PT:
- Anemia, Diminished O2 transport*, DECd ability to maint. blood volumes
23
Q
Chronic Kidney Disease (CKD)
Comorbid w/ _____ and ______ ===== what?
A
Comorbid w/ HTN and heart disease
=> Significant precautions for exercise programs****
24
Q
CKD
Comorbid w/ HTN and heart disease==> Sig. precautions for exercise programs
Recommended Activities→
A
- 40-70% target HR (USE RPE**)
- self-paced walking, TM, cycle erg
- 4-6x/week
- LOW intensity, Goal→ work up to 30mins activity
25
CKD
\*remember **requires dialysis or transplant**
**Can a Pt Exercise on Dialysis?**
**Rule to follow if PT _AFTER DIALYSIS_**
PRIORITIZE YOUR EXERCISES/INTERVENTIONS!!!
MOST _IMPORTANT_ THINGS _FIRST_!!!
26
CKD
\*remember **requires dialysis or transplant**
**Can a Pt Exercise on Dialysis?**
PRIORITIZE!
* TM, cycle erg, bed/chair ex's
* physical and cardiopulm function
* **\*INC exercise on NON-dialysis days→ you'll have better luck w/ them!!!**
27
Physical Activity Promotion in CKD
## Footnote
**_Instead_ of HR….USE \_\_\_\_\_-**
RPE\*\*\*\*
28
Promotion of Phys Activity in CKD
* **VITALS ARE VITAL!**
* **BP and RPE**
* Long warmup (when approp.)→ aerobic, strength
* Cool-down
* return of fluid and BP
* **RPE NOT HR\*\*\***
29
Promotion of Phys Activity in CKD
## Footnote
**Contraindications/Stop Exercise**
Lightheadedness, dizzy, **pain,** dyspnea
30
Promotion of Phys Activity in CKD
## Footnote
**WHY????????**
**Long-term adoption of exercise behaviors to _maintain_ functional capacities and QoL\*\*\***
**SO IMPORTANT!!!**
31
Skeletal Changes in CKD
## Footnote
**PRIMARY hormone responsible for this????**
Parathyroid\*\*\*
32
Skeletal Changes in CKD
\*\*\*\***SEE FIG. 18-7, GOODMAN, P.971**
**GFR, Phosphate retention, Calcitrol**
**This is what you think of _initially_ as soon as you see “Skeletal changes in CKD”**
DEC GFR
INC Phosphate retention
DEC Calcitrol
**Know this!!!!!!!**
33
Skeletal Changes in CKD
## Footnote
**DEC GFR, INC phosphate retention, DEC calcitrol**
**_Explain_ the cascade of events that follows!**
**BE ABLE TO EXPLAIN VERBATIM!!!**
1. Changes **impair** **normal processes of bone mineralization**
2. **Parathyroid hormone (PTH) _mobilizes_ calcium from SK system to “help”→** mobilizes all this Ca+ bc thinks its doing good and helping!
3. Results→ **HypERphosphatemia** and **HypERcalcemia**
**\*\*Progression of vicious cycles leads to _Bone Turnover_**===\> rickets, osteomalacia, osteopenia, soft tissue calcification
34
1. Changes **impair** **normal processes of bone mineralization**
2. **Parathyroid hormone (PTH) _mobilizes_ calcium from SK system to “help”→** mobilizes all this Ca+ bc thinks its doing good and helping!
3. Results→ **HypERphosphatemia** and **HypERcalcemia**
**\*\*Progression of vicious cycles leads to _Bone Turnover_**===\> rickets, osteomalacia, osteopenia, soft tissue calcification
**All of this means that WHAT is important w/ our CKD pts?????**
WEIGHT-BEARING EXERCISES!!!!!!!!!
## Footnote
**partial wall sits, step ups, mini squats, wt bearing!!!!**
35
**Type I Diabetes** & Kidney Disease
## Footnote
**Albumin**
* **MICROalbuminuria**
* 20-30% after 15yrs
* \<50% progress to nephropathy
* **MACROalbuminuria**
* PRO \>300 mg/day
* **\*MAJORITY progress to ESRD**
36
**Type I Diabetes** & Kidney Disease
## Footnote
**End Stage Renal Disease**
16% @ 30yrs
37
**Type I Diabetes** & Kidney Disease
## Footnote
**IF no _proteinuria_ (PRO in urine) after 25yrs……**
Risk only 1% per year
38
TI DM & Kidney Disease go
**Go hand-in-hand!!!!**
39
**Type II Diabetes &** Kidney Disease
## Footnote
**10 yrs after Dx….. Albumin?**
MICROalbuminuria→ 25%
MACROalbuminuria→ 5%
\*Yearly progression from MICROalbuminuria 2-3%
40
**Type II Diabetes &** Kidney Disease
## Footnote
**Some _ethnic groups_ @ HIGHER risk of progression**
1. African-Americans\*
2. Mexican-Americans
3. Native Americans (Pima Indians)
41
**Prevention** of Nephropathy
ALL (then broken down)
* Glycemic control
* HTN control
* **BP \<130/80**
* Meds
* **ACE Inhibitors**
* **Angiotensin Receptor Blockers-ARBs (bc inflamm response)**
* Dyslipidemia control
42
**MOST COMMON _ADULT_ RENAL NEOPLASM**
\*90% OF ALL RENAL TUMORS
Renal Cell Carcinoma
43
What should you remember about **Renal Cell Carcinoma?**
MOST COMMON _adult_ renal neoplasm
\*90% of all renal tumors
44
Renal Cell Carcinoma (RCC)
## Footnote
**Pathogenesis:**
**Urine** contains **waste products, Obesity** contributes to **inflammation (and release of Angio II)**
45
Renal Cell Carcinoma (RCC):
## Footnote
**Overview**
* \***MOST COMMON _adult_ renal cell neoplasm**
* **M\>F; people of color\>Caucasian**
* **Risks:**
* smoking, mod-heavy drinking, obesity/HTN/bbq meat, occupational exposure (dust), organic solvents, asbestos, gene abnorms
* **Pathogen:** Urine contains waste products, obesity=inflammation
46
Renal Cell Carcinoma (RCC):
## Footnote
**Clinical Presentation**
**DEFINITELY REMEMBER THESE ONES!!!!**
**Flank pain, _Hematuria_ (blood in urine), palpable abdom. mass**
**\*Cough** and/or bone pain **commonly reported→ IMPORTANT!**
\*NOTE: **Flank pain=** pain either side of low back bw pelvis & ribs
47
Renal Cell Carcinoma RCC:
## Footnote
**Clinical Presentation**
**_Metatstatic sites:_ in order**
* **Lungs→** regional lymph nodes→ bone→ liver
48
Renal Cell Carcinoma RCC:
## Footnote
**More clinical presentation**
* 50% cases discovered **incidentally** bc renal cx's are **silent**
* NON-specific sx's→ malaise, anemia, wt loss
* Fever, HTN, hepatic dysf and hypERcalcemia occur bc **hormone production by tumors**
* 25-30% have metastatic dis by time of dx→ **5yr survival of 0-7% in presence of mult. mets**
49
Renal Cell Carcinoma: **Summary of Medical Mx:**
## Footnote
**PRIMARY FEATURE**
Renal parenchymal mass
50
Renal Cell Carcinoma: **Summary of Medical Mx:**
## Footnote
**PRIMARY TX:**
SURGERY
1. Radical nephrectomy
2. Removal of metastatic lesions **does not improve survival\***
51
Renal Cell Carcinoma: **Summary of Medical Mx:**
## Footnote
**More on this..**
* Dx imaging→ abdominal US, MRI, CT
* Chemo NOT gen. effective
* **40% of locally removed renal tumors recur\*\*\***
52
RCC: **Staging**
## Footnote
**ALL**
* **I=** tumor **w/in** capsule
* **II=** tumor **invades perirenal fat**
* **III=** tumor **extends into renal vein** or **regional lymphatics**
* **IV= distant mets present**
53
Bladder Cx:
## Footnote
**Overview**
* **4th** leading cause of cx in **men**, **8th** leading cause in **all of U.S.A**
* **Risk Factors:**
* smoking (2x more likely to dev.), male/Euro descent/55+ yrs old, exposure to chemicals/toxins, **bladder conditions, chronic inflamm, chemo/radiation**
54
Bladder Cx:
## Footnote
**Pathogenesis**
* Contact chemical carcinogenesis (**urine-soluble carcinogens contact urinary epithelium for long pds time),** genetic defects in tumor-suppressed gene, inability to repair DNA w/ damage
Aka waste products/carcinogens keep contacting bladder wall= irritation\*\*\*
55
Bladder Cx: **Clinical Presentation**
## Footnote
**MOST COMMON SIGN**
PAINLESS **hematuria**
* SUDDEN onset, intermittent freq, may lead to clots (pass clots in urine)
* \***Degree of _hematuria_ is NOT INDICATIVE of _stage of cx_**
56
Bladder cx: **more on Clinical Presentation**
* MOST COMMON→ _Painless_ **hematuria**
* Voiding dysf.
* INCd freq, urgency
* **When _more severe_→ lymphedema of LEs, LBP (referral from bladder)**
57
Bladder Cx:
## Footnote
**Prevention & Dx Testing**
* **Prevention→** mitigate risk factors (ex. smoking)
* **Dx Testing→** limtd dx screening available
* Dx initially made thru tests of urine and bladder cells
* + or inconclusive→ CT or US
58
Bladder Cx: **Summary of Med Intervention**
## Footnote
**ALL DETAILS**
* Depends on **staging** of tumor→ depends on **depth of tissue invasion**
* Unclear **optimal** tx for non-invasive dis.
* **Transurethral resection→** BCG immunotherapy==\> **_Primary tx_ for _Early stage dis._**
* Cysectomy and/or chemo=\> **_Primary tx_ for _Invasive disease_**
59
Bladder Cx: **Summary of Med Intervention**
## Footnote
**Depends on \_\_\_\_\_\_, which depends on\_\_\_\_\_\_\_**
Depends on **staging of tumor**, which depends on **depth of tissue invasion**
60
Bladder Cx: **Summary of Med Intervention**
## Footnote
**PRIMARY TX for _Early Stage Disease_**
Transurethral resection, f/b BCG Immunotherapy
61
Bladder Cx: **Summary of Med Intervention**
## Footnote
**PRIMARY Tx for _Invasive Disease_**
Cysectomy and/or Chemo
62
Bladder Cx: **Staging using TNM**
## Footnote
**Tumor staging (TNM) depends on……**
DEPTH of Tissue invasion
63
TNM explained:
* **T (Tumor) =** how far the main (primary) **Tumor** has grown thru the bladder wall AND whether it has grown into nearby tissues
* **N (Nodes) =** any cx spread to lymph **nodes** near the bladder
* **M (Metastasized) =** if cx has spread to _distant sites_ (mets)
64
TNM:
T=
Tumor
65
TNM
N=
Nodes
66
TNM
M=
Metastases
67
Bladder Cx Staging:
## Footnote
**T= Tumor**
**T1 vs T2**
**74% of bladder tumors= T1 or T2**
* **T1→** tumors thru **basement memb.** and **invaded into submucosa/lamina propria** but NOT muscularis propria
* **T2→** tumors invade muscular propria
68
Bladder Cx Staging
## Footnote
**N= Nodes**
**N0, N1, N2**
* **N0→** NO involvement
* **N1→** nodes **near** bladder
* **N2→** nodes **further** **away**
69
Bladder Cx Staging:
## Footnote
**M= Mets**
**Order for mets???**
Lung→ Liver→ Bone
## Footnote
**LLB!!!!**
70
Bladder Cx: **Surgical Intervention for _Early Stage_**
## Footnote
**Stage 0,1**
Transurethral Resection (remember from pelvic health!)
* For **early, superficial tumors**
* scope thru urethra→ remove lesions
* tumor bed tx'd w/ laser/electric current to destroy tissue
\***F/b BCG= intravesical immunotherapy**
71
Bladder Cx: **Surgical Intervention for _Early Stage_**
## Footnote
**Transurethral Resection _Complications_:**
**Short-term vs. Long-term**
* **Short-term→** bleeding, pain
* **Long-term→** fibrosis of bladder, loss of cont.
72
Albumin lvls and the Kidney
see pics
