Renal Disorders (Part 2) Flashcards
List the 3 categories of kidney dysfunction based on mechanism of injury
1) Prerenal
2) Intrarenal
3) Post renal
Prerenal kidney dysfunction
Decrease in BF & perfusion
Intrarenal kidney dysfunction
Secondary to actual injuries to the kidney itself
Post renal kidney dysfunction
Related to obstruction of urine outflow from the kidneys
List 11 causes of prerenal disorders
1) Hypotension
2) Shock
3) Diarrhea (severe)
4) Vomiting (severe)
5) Bleeding/ hemorrhage
6) Diuretics
7) Diabetes Insipidus
8) Burns
9) Heart failure/ MI
10) Cirrhosis
11) Sepsis
List 11 causes intrarenal disorders
1) Vasculitis
2) Venous occlusion
3) Preeclampsia
4) Acute tubular necrosis
5) Multiple myeloma
6) Hypercalcemia
7) IV contrast dyes
8) Pyelonephritis
9) Certain meds: NSAIDs, ACE inhibitors, heavy metals
10) Transfusion reactions
11) Rhabdomyolysis
List 7 causes of Post-renal disorders
1) Renal calculi
2) Enlarged prostate
3) Cancer
4) Diabetes
5) Functional obstruction due to drugs
6) Blood clots
7) Trauma
What is the most common cause of acute kidney injury?
Acute tubular necrosis (ATN)
What is acute tubular necrosis (ATN)?
Damage to renal tubules causing cells to slough into the tubular lumen & lumen becomes blocked
What happens in ATN when fluid is unable to go through the lumen?
Decreases urine formation → ultimately no urine if untreated
What does a blocked lumen in ATN cause?
It exacerbates ischemic injury to cells and causes additional intrarenal injury
List 2 causes of ATN
1) Post-ischemia
2) Nephrotoxins
List 3 things that can cause/ are r/t nephrotoxicity
1) Aminoglycosides
2) IV contrast dyes
3) Multiple myeloma
True or false:
If ATN is not reversed it can lead to permanent injury
TRUE
Normal creatinine clearance values
100-150 cc/ min
Prerenal Azotemia creatinine clearance values
15-80 cc/min
ATN creatinine clearance values
< 5-10 cc/min
Normal urine sodium lab values
10-20 mEq/ L
Prerenal azotemia urine sodium lab values
< 10 mEq/ L
ATN urine sodium lab values
> 20 mEq/ L
Normal specific gravity lab values
1.005-1.025
Prerenal azotemia specific gravity lab values
> 1.015
ATN specific gravity lab values
1.010 fixed
Normal urine osmolality lab values
200-1200 mOsm/ kg
Prerenal azotemia urine osmolality lab values
Concentrated > 450 mOsm/ kg
ATN urine osmolality lab values
Isomotic = 300 mOsm/ kg
Normal Serum BUN/ Cr lab values
BUN = 10-20
Prerenal azotemia BUN/ Cr lab values
BUN = > 15:1
ATN BUN/ Cr lab values
BUN = 10:1 fixed
Prerenal azotemia urinalysis findings
Normal
ATN urinalysis findings
Red/ white cells, casts, epithelial cells
Urine output considered oliguria
< 400 mL/ day
Urine output considered anuria
30-40 mL/ day
Prerenal azotemia is due to…
decreased renal BF
Along with abnormal creatinine levels what other lab would be abnormal in azotemia?
Ammonia levels
Phases of AKI:
Initial onset
0-2 days
Initial insult to point when BUN/Cr rise &/or urine output drops
Phases of AKI:
Oliguria Hint: 2
1-2 days to 6-8 weeks
1) Drop in GFR, retention of urea, K+, sulfate, & Cr
2) Decrease urine output & edema
Phases of AKI:
Late diuretic
2-8 days
Begins with slow, gradual increase in urine output, then high output (up to 10 L in 24 hrs)
Phases of AKI:
Recovery
2-4 mos
Labs return to pre-morbid state (full recovery; diabetics may not fully return)
List 3 things that should be included in diet for AKI recovery
1) Low sodium diet
2) Fluid restriction (IV or PO)
3) Low potassium diet
List 2 of the most common causes of AKI
1) Septic shock
2) Cardiac shock
List 4 clinical manifestations of AKI
1) Oliguria
2) Fluid overload
3) Build up of nitrogenous waste
4) Edema
List 4 clinical manifestations seen as a result of build up nitrogenous waste in AKI
1) Uremia
2) Metabolic acidosis
3) Thromobcytopenia
4) Neuromuscular irritability
List 5 labs we look at when Dx AKI
1) Urinalysis
2) Serum electrolytes
3) BUN/ Cr
4) Arterial blood gases
5) CBC
List 2 other ways to Dx AKI
1) Imaging → CT scan
2) Renal biopsy
What is the goal of AKI Tx?
Restore normal chemical balance, prevent further complications until repair of renal tissue & restoration of renal function occurs
List 5 Tx options for AKI
1) Fluid administration
2) Loop diuretics (Furosemide/ Lasix)
3) Monitor electrolyes → K+
4) Cardiac monitoring
5) Hemodialysis
List 3 things that would be important to monitor for a pt with AKI
1) I & O
2) BP
3) Might need daily weights
List 3 types of hospital units a pt with AKI would be put on for cardiac monitoring
1) Telemetry unit
2) Step down
3) ICU
What is the purpose of hemodialysis in AKI Tx?
Helps maintain a little bit more of a homeostatic state
Hope is to get ppl off dialysis
What is the leading cause of death in AKI
Hyperkalemia
Why is hyperkalemia the leading cause of death in AKI?
K+ plays a role on muscles & nerves → supposed to be in ICF, so when it gets out into ECF levels become too high & affects muscles (esp the most important one: heart!)
List 5 indications for dialysis
1) Volume overload
2) K+ > 6 mEq/ L
3) Metabolic acidosis/ serum HCO3- > 0.15 mEq/ L
4) BUN > 120 mg/dL
5) Other signs of uremic intoxication
List 9 signs of uremic intoxication
1) N/V
2) Decreased appetite
3) Weight loss
4) Fatigue
5) Impaired cognition
6) Muscle cramps
7) Metallic taste
8) Seizure
9) Coma
What is an irreversible, progressive kidney disease?
Chronic kidney disease (CKD)
Sx of CKD
Often asymptomatic initially until disease is far advanced
80% of nephrons are impacted
Umbrella term for CKD
Kidney damage; or GFR < 60 mL/min/1.73 m2 for ≥ 3 mos
List 6 causes of CKD
1) Hypertension
2) Diabetes
3) Obesity
4) Glomerulonephritis
5) SLE
6) Polycystic kidney disease
Explain what happens in CKD Hint: 2
1) Loss of functioning nephrons, progressive deterioration of GF, ability of tubules to reabsorb, endocrine functions
2) As nephrons are destroyed remaining hypertrophy to take on the work
Stages of renal dysfunction:
Stage 1
Damage with normal or ↑ GFR (> 90mL/ min)
Stages of renal dysfunction:
Stage 2
Mild reduction in GFR (btwn 60-90 mL/min)
Stages of renal dysfunction:
Stage 3
Moderate reduction in GFR (btwn 30-59 mL/min)
Stages of renal dysfunction:
Stage 4
Severe reduction in GFR (btwn 15-29 mL/min)
Stages of renal dysfunction:
Stage 5
Kidney failure (GFR < 15 mL/min)
Kidneys no longer remove waste products or maintain normal function
What do most people with CKD die from?
A cardiac event
Sx & Tx of stages 1&2 of renal dysfunction Hint: 2
1) Often asymptomatic & Cr will be normal
2) Compensation will occur for damaged nephrons
Sx & Tx of stage 3 renal dysfunction Hint: 3
1) ↓ function b/c < 50% of nephrons are working
2) will see lab changes
3) No longer able to compensate
Sx & Tx of stage 4 renal dysfunction Hint: 3
1) Renal insufficiency is evident
2) Nephrons no longer able to do the job
3) Diet restriction of proteins
Tx of stage 5 renal dysfunction
Dialysis &/or Transplant
List 6 clinical manifestations of CKD
1) Accumulation of nitrogenous waste
2) Hyperkalemia
3) Hypocalcemia
4) Normochromic/ normocytic anemia
5) Low albumin
6) Hyperphosphatemia
List 2 things accumulation of nitrogenous waste in CKD can lead to
1) Encephalopathy
2) Anemia & thrombocytopenia due to lysis
Why do we see hypocalcemia in CKD? and what can it lead to?
B/c Vit. D is not able to be activated
1) Hyperparathyroidism
2) Bone breakdown
A pt with CKD & normocytic/ normochromic anemia may require…
Blood transfusion b/c they do NOT have erythropoietin production
Why does hyperphosphatemia occur in CKD?
Due to the hypocalcemia
What would the skin of a pt with CKD look like?
Grayish undertone b/c waste products & from the filtrates used in dialysis
List 10 Tx for CKD
1) Tx underlying cause
2) Monitor labs
3) Smoking cessation
4) Manage hyperglycemia
5) Manage anemia
6) Exercise programs
7) Decrease sodium
8) Avoid alcohol
9) Dialysis
10) Kidney transplant
What is glomerulonephritis?
Inflammation of the glomerular capillaries
What % of all ESRD cases are caused by glomerulonephritis?
25-30%
What is the most common cause of acute glomerulonephritis?
Post-streptococcal glomerulonephritis
List 9 Sx of glomerulonephritis
1) Pink/ cola colored urine
2) Proteinuria
3) Hematuria
4) HTN
5) Fluid retention/ edema
6) Decrease urine
7) N/V
8) Muscle cramps
9) Fatigue
List 4 complications associated with glomerulonephritis
1) Accumulation of wastes or toxins in the bloodstream
2) Poor regulation of essential minerals & nutrients
3) Loss of RBCs
4) Loss of blood proteins
Pathology of glomerulonephritis:
What does it begin with?
Antigen-antibody reaction/ complex that damages structures of the glomeruli which causes nephron dysfunction
Pathology of glomerulonephritis:
Ag-Ab complex leads to what 4 things
1) ↓ filtration of blood
2) ↓ urine production
3) Hypervolemia
4) HTN
What is often the first Sx of glomerulonephritis?
Oliguria
Where is edema often present in glomerulonephritis?
Face & hands
List 4 abnormal labs associated with glomerulonephritis
1) Elevated anti-strep Ab (ASO)
2) Increased Cr
3) Decreased serum albumin
4) Casts in urine (on urinalysis)
What are casts in urine? & what are they made up of?
Tiny tube shaped particles
→ WBCs, RBCs, Kidney cells, or substances (i.e. proteins/ fats)
Goal of Tx for glomerulonephritis Hint: 2
1) Increase urine output
2) Decrease urinary protein
List 4 medications used in Tx of glomerulonephritis
1) Corticosteroids
2) Abx
3) Antihypertensives
4) Antipyretics
List 2 diet modifications in Tx of glomerulonephritis
1) Low sodium
2) Low protein
List 3 complications to monitor for when treating glomerulonephritis
1) HTN encephalopathy
2) HF
3) Pulmonary edema
What is nephrotic syndrome
Damage to the glomerulus
→ filter is damaged; things which should stay in can now leak out through pores which become bigger due to the damage
Nephrotic syndrome leads to an increased…
Permeability of proteins & other substances in the blood
What is the most common cause of nephrotic syndrome?
Diabetic neuropathy
List 3 top causes of nephrotic syndrome that account for 90% of cases
1) Diabetic neuropathy
2) Lupus
3) Amyloidosis
List 5 other causes of nephrotic syndrome
1) Vasculitis
2) Allergies
3) Preeclampsia
4) HTN
5) Other infections
List 2 clinical manifestations of nephrotic syndrome
1) Albuminuria (AKA proteinuria)
→ may also see WBCs in urine
2) Edema
List the 5 lab studies to be completed for nephrotic syndrome & what you would see
1) Urinalysis → Proteinuria; hematuria
2) Elevated BUN/Cr
3) Low serum albumin
4) Tests for lupus, Hep B & C
5) 24 hr urine
List 2 other diagnostic tests for nephrotic syndrome
1) Renal ultrasound
2) renal biopsy
List 3 dietary modifications for Tx of nephrotic syndrome
1) Low sodium
2) Low protein
3) Adequate fluid intake, but avoid fluid overload
List 2 vaccines given for Tx of nephrotic syndrome
1) Pneumococcal
2) Influenza
List 2 medications given for Tx of nephrotic syndrome
1) ACE inhibitors
2) ARBs
List 2 complications to monitor for when treating nephrotic syndrome
1) Hyperlipidemia
2) Thromboembolism → clot in renal vein
Nephrotic vs. Nephritic:
Which disorder increases glomerular permeability?
Nephrotic syndrome
Nephrotic vs. Nephritic:
Which disorder produces an inflammatory response? & what is it r/t?
Nephritic syndrome
→ r/t immune complexes & Ab-Ag complexes lodged in capillaries
→ develops against the Ag
Nephrotic vs. Nephritic:
Which disorder has a massive loss of plasma proteins in the urine?
Nephrotic syndrome
Nephrotic vs. Nephritic:
List 4 alterations in body functions due to nephrotic syndrome
1) Generalized edema
2) Elevated triglycerides and LDL
3) Na+ & water retention
4) Ascites +/-
Nephrotic vs. Nephritic:
Nephritic syndromes inflammatory processes occlude ___ ___ ___ & damages ___ ___
1) Occludes glomerular capillary lumen
2) Damages capillary wall
The damage to the capillary walls in nephritic syndrome allows what?
Allows RBCs to escape into the urine
Nephrotic vs. Nephritic:
List 5 reasons we see bodily function alterations in nephritic syndrome
1) Decrease in GFR
2) Fluid retention
3) Nitrogen waste accumulation
4) Proteinuria
5) Oliguria
Post-strep glomerular nephritis is typically seen in what ages?
4-7 yrs
Nephrotic syndrome is typically seen in what ages?
2-3 yrs (esp. males)
Onset of post-strep glomerular nephritis
10-14 days after strep infections
Anti-streptolysin titer in post-strep glomerular nephritis & nephrotic syndrome
Positive → post-strep
Negative → nephrotic
Urine findings in post-strep glomerular nephritis & nephrotic syndrome
Post-strep → cola colored
Nephrotic → clear
Hematuria in Post-strep glomerular nephritis & nephrotic syndrome
Post-strep → massive hematuria
Nephrotic → microscopic
Proteinuria in Post-strep glomerular nephritis & nephrotic syndrome
Post-strep → minimal
Nephrotic → Massive
BP findings in post-strep glomerular nephritis & nephrotic syndrome
Post-strep → HTN
Nephrotic → normal or slightly ↓
Albumin in blood in nephrotic syndrome
Hypoalbuminemia → b/c its in the urine (hyperalbuminuria)
Edema in post-strep glomerular nephritis & nephrotic syndrome
Post-strep → moderate edema
Nephrotic → massive edema
Potassium in post-strep glomerular nephritis & nephrotic syndrome
Post-strep → Hyperkalemia
Nephrotic → normal
BUN findings in post-strep glomerular nephritis & nephrotic syndrome
Post-strep → elevated BUN
Nephrotic → normal BUN
Which disorder can we see hyperlipidemia in: post-strep glomerular nephritis or nephrotic syndrome?
Nephrotic syndrome
List 3 things to remember ab Diabetes in relation to the kidneys
1) thickening of basement membrane
2) Dysfunction of glomerular podocytes (cover urinary side of glomerular basement membrane)
3) Inflammation (T cells & macrophages) into glomerulus
List 2 things to remember ab HTN in relation to the kidneys
1) Vascular changes (vasoconstriction)
2) Glomerular changes
→ damage to basement membrane (podocytes)
→ allows plasma proteins to escape
4 things to remember about otc NSAID use & the impact on renal function
1) NSAIDs work by inhibiting prostaglandins (esp. COX1)
2) Renal prostaglandins protect against ↓ renal flow
3) Prostaglandin inhibition can depress already ↓ renal BF
4) Leads to reduction in renal perfusion & decreased GFR
Those most at risk for complications from NSAID use Hint: 6
1) Dehydration → esp. older adults
2) Arterial volume depletion → HF, Nephrotic syn, cirrhosis
3) CKD esp stage 3 or worse
4) Volume depletion from aggressive diuresis, vomiting, diarrhea
5) Older age
6) Severe hypercalcemia w/ associated renal arteriolar vasoconstriction
What disorder can cause hypercalcemia?
Multiple myeloma → releases Ca++ into ECF
What can happen during extreme exercises r/t renal function? Hint: 3
1) Esp. in heat the skin & muscle compete for BF
2) When exercising at max GFR can be reduced by 30-60%
3) Dehydration & heat stress
Fluid intake when taking NSAIDs (even when healthy)
MUST drink a lot of fluids
Increase fluids in athletes
List 3 times to avoid NSAID use
1) Avoid NSAID use outside of recommended doses
2) Avoid NSAID use in states of dehydration
3) Avoid in those with HTN, HF, DM, & metabolic syndrome
How should NSAIDs be taken as an anti-inflammatory?
Use for shortest time & try to use acetaminophen as well (go back & forth)
