Renal Diseases (Exam III) Flashcards
1
Q
Which vertebrae are the kidney’s typically situated between?
A
T12 - L3
2
Q
Which kidney is slightly more posterior? Why?
A
Right kidney is more posterior to accommodate the liver.
3
Q
What stimulates erythropoietin release from the kidneys?
A
Inadequate O₂ to the kidneys
4
Q
How much of CO do the kidneys receive?
A
20 - 25% ( 1-1.25L/min)
5
Q
What is Azotemia?
What causes it?
A
- Abnormally high levels of nitrogen containing compounds such as Urea and Creatinine.
- Azotemia is causes by dysfunctional kidneys.
6
Q
Where are your osmolality sensors located?
What occurs when you have hyperosmolality?
A
- Anterior Hypothalamus
- Hypothalamus signals pituitary gland to stimulate thirst and secrete ADH.
7
Q
What degree of hyponatremia would give you pause for surgery?
A
Less than 125 mg/dL
8
Q
What are some conditions (discussed in lecture) that can cause hyponatremia?
A
- Prolonged sweating
- Vomiting/diarrhea
- Insufficient aldosterone
- Excessive H₂O intake
9
Q
How would hyponatremia be treated?
A
This is highly dependent on underlying pathology.
- Treatment of underlying disease
- NS
- Hypertonic Saline
- Lasix
- Mannitol
10
Q
What pathology could occur with rapid over-correction of hyponatremia?
A
Osmotic Demyelination Syndrome (“Locked-in Syndrome”)
11
Q
At what degree of hypernatremia would you typically cancel surgery?
A
155 mg/dL or greater
12
Q
What is the most common cause of hypernatremia?
A
Insufficient replacement of water loss
Rarely caused by excessive Na⁺ intake
13
Q
What is the complication from rapid correction of hypernatremia?
A
There is little evidence of morbidity from rapid hypernatremia correction. 0.5 mmol/L/hr to an absolute change of 10 mmol/L/day would be best to avoid cerebral edema, seizures, and other neurological sequelae.
14
Q
Severe hyponatremia/hypernatremia both result in what?
A
Seizures, coma, and death
15
Q
What are normal levels of serum potassium?
A
3.5 - 5 mg/dL
16
Q
Excessive intake of what food is known to cause hypokalemia?
A
Licorice
17
Q
When does hypokalemia need to be treated with K⁺ repletion?
A
Serum K⁺ < 3 mg/dL
18
Q
What types of symptoms are generally seen with hypokalemia?
A
Cardiac & neuromuscular
19
Q
What EKG sign is seen with hypokalemia?
A
“U”-waves
20
Q
What other lab needs to be check when replenishing K⁺ ?
A
Serum Phosphorus
21
Q
A patient presents with a gun shot wound to the thorax necessitating exploratory thoracostomy. The patient’s serum K⁺ level is 5.7 mg/dL, what do you do?
A
- Emergent surgery so proceed and treat the hyperkalemia
If the surgery was not emergent you would treat the K⁺ til it was below 5 mg/dL.
22
Q
What are hyperkalemia’s effects on on EKG?
What about on the cardiac cellular membrane?
A
- Peaked “T” Waves
- ↓ Vᵣₘ and ↓ APD (action potential duration)
23
Q
What is the treatment for hyperkalemia?
A
“C BIG K”
- Calcium gluconate (1° treatment)
- Bicarbonate
- Insulin
- Glucose
- Kayexelate
24
Q
What is a normal GFR?
A
125 - 140 mL/min
25
What is normal serum creatinine?
0.6 - 1.2 mg/dL
26
What is better for acute monitoring of renal function, GFR or creatinine?
- Creatinine for acute monitoring
- GFR for chronic/trending
27
A 100% increase in creatinine is indicative of a _____ decrease in GFR.
50%
28
What populations would have lower creatinine levels?
Who would have higher?
- ↓ in women and elderly
- ↑ in body builders
29
What is the normal BUN:Creatinine ratio?
10:1
30
What is normal urine specific gravity?
1.001 - 1.035
31
What is normal BUN?
8 - 20 mg/dL
32
Large amounts of what macromolecule would be suggestive of glomerular injury?
protein
33
What is the primary metabolite of protein metabolism in the liver?
Urea
*Amino acids → ammonia → urea*
34
Which of these two compounds is subject to filtration at the glomerulus?
- Creatinine
- Urea
Trick question. Both are subject to filtration
35
Which of these two compounds is subject to reabsorption in the nephron?
- Creatinine
- Urea
Urea is reabsorbed unlike creatinine ( and therefore can't be used to measure GFR)
36
What would a BUN:Creatinine ratio of greater than 20:1 indicate?
Pre-renal Azotemia
37
What is normal urine output in adults?
1 mL/kg/hr
38
Your pre-operative patient has had less than 500 mLs of urine output in the past 24 hours. How would you classify this patient?
Oliguric
39
What's the greatest risk factor for AKI?
Pre-existing renal disease
40
What lab values would be indicative of acute renal failure?
- Serum creatinine > 0.5 mg/dL
- 50% decrease in creatinine clearance
41
What is a typical BUN:Creatinine ratio in pre-renal AKI?
> 20:1
42
What is the most common cause of pre-renal AKI?
Renal Hypoperfusion
*shock, burns, trauma, blood loss, aortic clamping, etc.*
43
Differentiate pre-renal oliguria from Acute Tubular Necrosis.
44
What is a typical BUN:Creatinine ratio in intra-renal AKI?
< 15:1
45
Why are urea levels higher in intra-renal AKI?
Whole nephron is failing so **urea is not being reabsorbed in the PCT.**
46
What is the cause of intra-renal AKI?
Renal parenchymal (inner kidney) damage
*ATN, glomerulonephritis, CKD, etc.*
47
What is the cause of post-renal azotemia?
Urinary tract blockage
48
what does a low BUN indicate
malnutrition, liver damage, too much resucitation?
49
What does BUN: creatinne ratio help us determine?
fluid hydration status
50
what causes renal azotemia
reperfusion injury... cytokines, oxygen free radical, inflammatory cells
51
What BUN:Creatinine ratio is typically seen in post-renal AKI?
- Initial: > 15:1
- Persistent creates decreased BUN:Cr
52
What is the most common neurological complication of AKI?
Uremic Encephalopathy
53
which anesthetic is not dependent on renal excretion?
nimbex (plasma cholinesterase)
54
Which types of medications should you avoid for these patients?
lipid insoluble due to limited excretion (I.e. thiazide, loops, digoxin, lots of antibiotics, muscle relaxants, morphine, demerol
55
What are the most common cardiac complications of AKI?
- HTN
- LV hypertrophy
- CHF
- Pulm Edema
56
What are the most common hematologic complications of AKI?
- Anemia
- Plt dysfunction
57
What are the most common metabolic complications of AKI?
- **Hyperkalemia**
- H₂O & Na⁺ retention
- ↓ albumin
- Metabolic acidosis
58
What drug is given prophylactically to prevent acidemia and its complications in kidney patients?
Sodium bicarb
59
What are the leading causes of ESRD?
- DM
- HTN
60
What does the acronym RIFLE stand for?
**R**isk
**I**njury
**F**ailure
**L**oss
**E**nd-stage
61
What labs indicate "Risk" according to the rifle criteria for kidney disease?
- Creatinine 1.5x base
- UOP < 0.5 mL/kg/hr for more than 6 hours
62
What labs indicate "Injury" according to the rifle criteria for kidney disease?
- Creatinine 2x base
- UOP < 0.5 mL/kg/hr for more than 12 hours
63
What labs indicate "Failure" according to the rifle criteria for kidney disease?
- Creatinine 3x base
- UOP < 0.3 mL/kg/hr for > 12 hours *or* total anuria for > 12 hrs
64
What labs indicate "Loss" according to the rifle criteria for kidney disease?
Renal replacement therapy needed for > 4 weeks
65
What labs indicate "End-stage" according to the rifle criteria for kidney disease?
Renal replacement therapy needed for > 3 months
66
On average, GFR decreases by _____ per decade starting from age 20.
10 ml/min
67
Which population is more likely to have kidney failure compared to other americans?
Hispanic Americans
Mario :(
68
It is usually helpful to assume that everyone with CKD also has this condition.
CAD
69
What drugs are often used to combat chronic kidney disease?
ACEi's and ARBs
70
How do ACEi's and ARBs help treat CKD?
- Decrease systemic & glomerular HTN
- Decrease proteinuria
- Decrease glomerular sclerosis
71
What antihypertensive drugs need to be held on the day of surgery to decrease the risk of intraoperative hypotension?
ACEi's & ARBs
72
Which populations are at a higher risk for silent MI?
Women and diabetics
73
What lab values reflect dyslipidemia?
- Triglycerides > 500
- LDL > 100
74
What are the indications for dialysis?
- Volume overload
- ↑K⁺
- Severe metabolic acidosis
- Symptomatic uremia
- Drug overdose
75
What is the most common adverse event associated with dialysis?
Hypotension
76
What is the leading cause of death in dialysis patients?
Infection
77
When would peritoneal dialysis be preferred to hemodialysis?
PD is preferred for patients who can't tolerate large fluid shifts (*CHF or unstable angina*)
78
What two things reduce the risk of pre-renal azotemia?
- Maintain MAP > 65mmHg
- Appropriate hydration
79
Excessive use of 0.9% NaCl leads to what condition?
Hyperchloremic metabolic acidosis
80
Which of the following fluids are associated with increased risk of renal injury?
- Crystalloids
- Colloids
- Starches
Starches
81
Treating oliguric AKI patients with diuretics helps improve their condition via diuresing toxic metabolic byproducts of the AKI. T/F?
False. Diuretics in a oliguric AKI can further the renal injury.
82
This drug maintains GFR and urine output better than norepinephrine and neosynephrine via preferential constriction of the efferent arteriole.
Vasopressin
83
What type of anesthesia is common for TURPs?
Neuraxial (Spinal to T10, usually)
84
What are the risks and benefits of NaCl used as irrigation fluid for TURPs?
- Risk: electric shock with unipolar cautery (only use bipolar electrocautery)
- Benefit: Very few side effects, good visibility
85
What are the risks and benefits of distilled water used as irrigation fluid for TURPs?
- Risk: ↑ risk of TURP syndrome
- Benefit: Very good visibility
86
What are the risks and benefits of glycine solution used as irrigation fluid for TURPs?
- Risk: ↑ ammonia = ↓LOC and blurry vision
- Benefit: ↓ risk of TURP syndrome
87
What are the risks and benefits of sorbitol solution used as irrigation fluid for TURPs?
- Risk: ↑BG, osmotic diuresis, and acidosis
- Benefit: ↓ risk of TURP syndrome.
88
What are the risks and benefits of Mannitol used as irrigation fluid for TURPs?
- Risk: Osmotic diuresis and transient plasma expansion.
- Benefit: Renally filtered and excreted (doesnt mess with the liver at all).
89
What is TURP syndrome?
What are its characterizing symptoms?
- Absorption of large volume of **hypo-osmolar** irrigation fluid.
- HTN, ↓HR, & LOC changes
90
How is TURP syndrome treated?
- Stop case
- If Na⁺ > 120mEq/L → Lasix
- If Na⁺ < 120mEq/L → 3% NaCl until at 120mEq/L.
- Benzos if seizing
91
How do urolithiasis patients typically present?
- Ca⁺⁺ stones
- Colicky pain in the ipsilateral flank & upper abdomen
- UTI and/or hematuria
92
What drugs are given with MET (medical expulsive therapy) for kidney stones?
- CCBs
- α-blockers
- corticosteroids
93
What is ESWL?
Extracorporeal ShockWave Lithotripsy
94
What is a patient getting a PCNL at high risk for?
pulmonary trauma (surigical procedure putting in stents before nephrostomy)
95
What cardiac considerations exists for ESWL?
- Avoid R-on-T phenomena
- Pacemakers/ICDs
- Calcified Aortic aneurysms
96
How is idiopathic hypercalciuria treated/
Thiazide diuretics
97
Why might you want to do regional or GA with paraplegic patients undergoing bladder surgeries?
To avoid autonomic dysreflexia. specifically pts with SCI of T7 or higher (deficits below T6)
