Renal Diseases (Exam III)

Question 1

Which vertebrae are the kidney’s typically situated between?

Answer 1

T12 - L3

Question 2

Which kidney is slightly more posterior? Why?

Answer 2

Right kidney is more posterior to accommodate the liver.

Question 3

What stimulates erythropoietin release from the kidneys?

Answer 3

Inadequate O₂ to the kidneys

Question 4

How much of CO do the kidneys receive?

Answer 4

20 - 25% ( 1-1.25L/min)

Question 5

What is Azotemia?
What causes it?

Answer 5

• Abnormally high levels of nitrogen containing compounds such as Urea and Creatinine.
• Azotemia is causes by dysfunctional kidneys.

Question 6

Where are your osmolality sensors located?
What occurs when you have hyperosmolality?

Answer 6

• Anterior Hypothalamus
• Hypothalamus signals pituitary gland to stimulate thirst and secrete ADH.

Question 7

What degree of hyponatremia would give you pause for surgery?

Answer 7

Less than 125 mg/dL

Question 8

What are some conditions (discussed in lecture) that can cause hyponatremia?

Answer 8

• Prolonged sweating
• Vomiting/diarrhea
• Insufficient aldosterone
• Excessive H₂O intake

Question 9

How would hyponatremia be treated?

Answer 9

This is highly dependent on underlying pathology.

• Treatment of underlying disease
• NS
• Hypertonic Saline
• Lasix
• Mannitol

Question 10

What pathology could occur with rapid over-correction of hyponatremia?

Answer 10

Osmotic Demyelination Syndrome (“Locked-in Syndrome”)

Question 11

At what degree of hypernatremia would you typically cancel surgery?

Answer 11

155 mg/dL or greater

Question 12

What is the most common cause of hypernatremia?

Answer 12

Insufficient replacement of water loss

Back home we called this dehydration.

Question 13

What is the complication from rapid correction of hypernatremia?

Answer 13

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.

Question 14

Severe hyponatremia/hypernatremia both result in what?

Answer 14

Seizures, coma, and death

Question 15

What are normal levels of serum potassium?

Answer 15

3.5 - 5 mg/dL

Question 16

Excessive intake of what food is known to cause hypokalemia?

Answer 16

Licorice

Question 17

When does hypokalemia need to be treated with K⁺ repletion?

Answer 17

Serum K⁺ < 3 mg/dL

Question 18

What types of symptoms are generally seen with hypokalemia?

Answer 18

Cardiac & neuromuscular

Question 19

What EKG sign is seen with hypokalemia?

Answer 19

“U”-waves

Question 20

What other lab(s) needs to be check when replenishing K⁺ ?

Answer 20

Serum Phosphorus and Mg⁺⁺

Question 21

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?

Answer 21

• 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.

Question 22

What are hyperkalemia’s effects on on EKG?
What about on the cardiac cellular membrane?

Answer 22

• Peaked “T” Waves
• ↑ Vᵣₘ and ↓ APD (action potential duration)

Question 23

What is the treatment for hyperkalemia?

Answer 23

“C BIG K”

• Calcium gluconate (1° treatment)
• Bicarbonate
• Insulin
• Glucose
• Kayexelate

Question 24

What is a normal GFR?

Answer 24

125 - 140 mL/min

Question 25

What is normal serum creatinine?

Answer 25

0.6 - 1.2 mg/dL

Question 26

What is better for acute monitoring of renal function, GFR or creatinine?

Answer 26

- Creatinine for acute monitoring - GFR for chronic/trending

Question 27

A 100% increase in creatinine is indicative of a _____ decrease in GFR.

Answer 27

50%

Question 28

What populations would have lower creatinine levels? Who would have higher?

Answer 28

- ↓ in women and elderly - ↑ in body builders

Question 29

What is the normal BUN:Creatinine ratio?

Answer 29

10:1

Question 30

What is normal urine specific gravity?

Answer 30

1.001 - 1.035

Question 31

What is normal BUN?

Answer 31

8 - 20 mg/dL

Question 32

Large amounts of what macromolecule would be suggestive of glomerular injury?

Answer 32

protein

Question 33

What is the primary metabolite of protein metabolism in the liver?

Answer 33

Urea *Amino acids → ammonia → urea*

Question 34

Which of these two compounds is subject to filtration at the glomerulus? - Creatinine - Urea

Answer 34

Trick question. Both are subject to filtration

Question 35

Which of these two compounds is subject to reabsorption in the nephron? - Creatinine - Urea

Answer 35

Urea is reabsorbed unlike creatinine ( and therefore can't be used to measure GFR)

Question 36

What would a BUN:Creatinine ratio of greater than 20:1 indicate?

Answer 36

Pre-renal Azotemia

Question 37

What is normal urine output in adults?

Answer 37

1 mL/kg/hr

Question 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?

Answer 38

Oliguric

Question 39

What's the greatest risk factor for AKI?

Answer 39

Pre-existing renal disease

Question 40

What lab values would be indicative of acute renal failure?

Answer 40

- Serum creatinine increase by > 0.5 mg/dL - 50% decrease in creatinine clearance

Question 41

What is a typical BUN:Creatinine ratio in pre-renal AKI?

Answer 41

> 20:1

Question 42

What is the most common cause of pre-renal AKI?

Answer 42

Renal Hypoperfusion *shock, burns, trauma, blood loss, aortic clamping, etc.*

Question 43

Differentiate pre-renal oliguria from Acute Tubular Necrosis.

Answer 43

Question 44

What is a typical BUN:Creatinine ratio in intra-renal AKI?

Answer 44

< 15:1

Question 45

Why are urea levels (in the urine) higher in intra-renal AKI?

Answer 45

Whole nephron is failing so **urea is not being reabsorbed in the PCT.**

Question 46

What is the cause of intra-renal AKI?

Answer 46

Renal parenchymal (inner kidney) damage *ATN, glomerulonephritis, CKD, etc.*

Question 47

What is the cause of post-renal azotemia?

Answer 47

Urinary tract blockage

Question 48

What BUN:Creatinine ratio is typically seen in post-renal AKI?

Answer 48

- Initial: > 15:1 - Chronic = ↓ BUN:Cr

Question 49

What is the most common neurological complication of AKI?

Answer 49

Uremic Encephalopathy

Question 50

What are the most common cardiac complications of AKI?

Answer 50

- HTN - LV hypertrophy - CHF - Pulm Edema

Question 51

What are the most common hematologic complications of AKI?

Answer 51

- Anemia - Plt dysfunction

Question 52

What are the most common metabolic complications of AKI?

Answer 52

- **Hyperkalemia** - H₂O & Na⁺ retention - ↓ albumin - Metabolic acidosis

Question 53

What drug is given prophylactically to prevent acidemia and its complications in kidney patients?

Answer 53

Sodium bicarb

Question 54

What are the leading causes of ESRD?

Answer 54

- DM - HTN

Question 55

What does the acronym RIFLE stand for?

Answer 55

**R**isk **I**njury **F**ailure **L**oss **E**nd-stage

Question 56

What labs indicate "Risk" according to the rifle criteria for kidney disease?

Answer 56

- Creatinine 1.5x base - UOP < 0.5 mL/kg/hr for more than 6 hours

Question 57

What labs indicate "Injury" according to the rifle criteria for kidney disease?

Answer 57

- Creatinine 2x base - UOP < 0.5 mL/kg/hr for more than 12 hours

Question 58

What labs indicate "Failure" according to the rifle criteria for kidney disease?

Answer 58

- Creatinine 3x base - UOP < 0.3 mL/kg/hr for > 12 hours *or* total anuria for > 12 hrs

Question 59

What labs indicate "Loss" according to the rifle criteria for kidney disease?

Answer 59

Renal replacement therapy needed for > 4 weeks

Question 60

What labs indicate "End-stage" according to the rifle criteria for kidney disease?

Answer 60

Renal replacement therapy needed for > 3 months

Question 61

On average, GFR decreases by _____ per decade starting from age 20.

Answer 61

10 ml/min

Question 62

Which population is more likely to have kidney failure compared to other americans?

Answer 62

Hispanic Americans

Question 63

It is usually helpful to assume that everyone with CKD also has this condition.

Answer 63

CAD

Question 64

What drugs are often used to combat chronic kidney disease?

Answer 64

ACEi's and ARBs

Question 65

How do ACEi's and ARBs help treat CKD?

Answer 65

- Decrease systemic & glomerular HTN - Decrease proteinuria - Decrease glomerular sclerosis

Question 66

What antihypertensive drugs need to be held on the day of surgery to decrease the risk of intraoperative hypotension?

Answer 66

ACEi's & ARBs

Question 67

Which populations are at a higher risk for silent MI?

Answer 67

Women and diabetics

Question 68

What lab values reflect dyslipidemia?

Answer 68

- Triglycerides > 500 - LDL > 100

Question 69

What are the indications for dialysis?

Answer 69

- Volume overload - ↑K⁺ - Severe metabolic acidosis - Symptomatic uremia - Drug overdose

Question 70

What is the most common adverse event associated with dialysis?

Answer 70

Hypotension

Question 71

What is the leading cause of death in dialysis patients?

Answer 71

Infection

Question 72

When would peritoneal dialysis be preferred to hemodialysis?

Answer 72

PD is preferred for patients who can't tolerate large fluid shifts (*CHF or unstable angina*)

Question 73

What two things reduce the risk of pre-renal azotemia?

Answer 73

- Maintain MAP > 65mmHg - Appropriate hydration

Question 74

Excessive use of 0.9% NaCl leads to what condition?

Answer 74

Hyperchloremic metabolic acidosis

Question 75

Which of the following fluids are associated with increased risk of renal injury? - Crystalloids - Colloids - Starches

Answer 75

Starches

Question 76

Treating oliguric AKI patients with diuretics helps improve their condition via diuresing toxic metabolic byproducts of the AKI. T/F?

Answer 76

False. Diuretics in a oliguric AKI can further the renal injury.

Question 77

This drug maintains GFR and urine output better than norepinephrine and neosynephrine via preferential constriction of the efferent arteriole.

Answer 77

Vasopressin

Question 78

What type of anesthesia is common for TURPs?

Answer 78

Neuraxial (Spinal to T10, usually)

Question 79

What are the risks and benefits of NaCl used as irrigation fluid for TURPs?

Answer 79

- Risk: electric shock with unipolar cautery (only use bipolar electrocautery) - Benefit: Very few side effects, good visibility

Question 80

What are the risks and benefits of distilled water used as irrigation fluid for TURPs?

Answer 80

- Risk: ↑ risk of TURP syndrome - Benefit: Very good visibility

Question 81

What are the risks and benefits of glycine solution used as irrigation fluid for TURPs?

Answer 81

- Risk: ↑ ammonia = ↓LOC and blurry vision - Benefit: ↓ risk of TURP syndrome

Question 82

What are the risks and benefits of sorbitol solution used as irrigation fluid for TURPs?

Answer 82

- Risk: ↑BG, osmotic diuresis, and acidosis - Benefit: ↓ risk of TURP syndrome.

Question 83

What are the risks and benefits of Mannitol used as irrigation fluid for TURPs?

Answer 83

- Risk: Osmotic diuresis and transient plasma expansion. - Benefit: Renally filtered and excreted (doesnt mess with the liver at all).

Question 84

What is TURP syndrome? What are its characterizing symptoms?

Answer 84

- Absorption of large volume of **hypo-osmolar** irrigation fluid. - HTN, ↓HR, & LOC changes

Question 85

How is TURP syndrome treated?

Answer 85

- Stop case - If Na⁺ > 120mEq/L → Lasix - If Na⁺ < 120mEq/L → 3% NaCl until at 120mEq/L. - Benzos if seizing

Question 86

How do urolithiasis patients typically present?

Answer 86

- Ca⁺⁺ stones - Colicky pain in the ipsilateral flank & upper abdomen - UTI and/or hematuria

Question 87

What drugs are given with MET (medical expulsive therapy) for kidney stones?

Answer 87

- CCBs - α-blockers - Corticosteroids

Question 88

What is ESWL?

Answer 88

Extracorporeal ShockWave Lithotripsy

Question 89

What cardiac considerations exists for ESWL?

Answer 89

- Avoid R-on-T phenomena - Pacemakers/ICDs - Calcified Aortic aneurysms

Question 90

How is idiopathic hypercalciuria treated?

Answer 90

Thiazide diuretics

Question 91

Why might you want to do regional or GA with paraplegic patients undergoing bladder surgeries?

Answer 91

To avoid autonomic dysreflexia.