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MED COMP PTS > renal dx > Flashcards

renal dx Flashcards

1
Q

Kidney Structure

A
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2
Q

nephron structure

A
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3
Q

glomerulus

A

where filtration occurs

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4
Q

afferent vs efferent arteriole

A

afferent: towards
efferent: away

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5
Q

bp affect at glomerulus

A

will influence filtration= too high will reduce function (hypertensive)

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6
Q

glomerular filtration

A

The hydrostatic pressure gradient forces glomerular filtration.
20% of renal plasma flow is filtered into Bowman’s capsule; hemodynamic factors contribute
to the filtration rate

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7
Q

influences of GFR

A

Glomerular Filtration Rate (GFR) affected by renal artery pressure other autoregulation factors of GFR:
1. vasoreactive (myogenic) reflex of afferent arteriole
2. tubuloglomerular feedback (TGF)
3. angiotensin II-mediated vasoconstriction of the efferent arteriole

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8
Q

. vasoreactive (myogenic) reflex of afferent arteriole

A
  • causes dilatation or constriction of the afferent arteriole to maintain stable glomerular pressure in response to variations in systole
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9
Q
  1. tubuloglomerular feedback (TGF)
A
  • causes dilatation or constriction of the afferent arteriole to maintain stable glomerular pressure in response to solute concentration changes detected by the macula densa cells in the distal/ascending Loop of
    Henle
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10
Q

Ang II GFR effect

A
  1. angiotensin II-mediated vasoconstriction of the efferent arteriole
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11
Q

where resorb, secrete, filter and excrete happen at nephron

A
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12
Q

Kidney Functions

A
  • Water regulation
  • Electrolyte regulation
  • Extracellular volume/pressure regulation
  • Acid-base homeostasis
  • Endocrine/metabolic
  • Blood plasma filtration
  • Excretion of metabolic waste
  • Urine production
  • Prostaglandin production
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13
Q

endocrine kidney functions

A

oKinins
oErythropoietin
oPhosphate
oVitamin D
oRenin

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14
Q

plasma filtration at kidney

A

oGlucose and amino acid reabsorption
oCalcium and phosphate regulation

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15
Q

Acute Kidney Injury (AKI)

A

A condition in which the kidneys suddenly can’t filter waste from the blood

Acute renal failure develops rapidly over a few hours or days. It may be fatal. It’s most common in those who are critically ill and already hospitalized

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16
Q

AKI uremia

A

Uremia results from the cumulative effects of renal failure, retention of excretory products,
and interference with metabolic and endocrine function

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17
Q

acute vs chronic renal more common?

A

chronic

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18
Q

symptoms AKI

A

decreased urinary output
swelling due to fluid retention
nausea
Fatigue
shortness of breath.
Sometimes symptoms may be subtle or may not
appear at all.

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19
Q

causes of ARF locations

A
  1. Pre-renal
  2. Intrinsic Renal
  3. Post-renal
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20
Q

pre renal ARF causes

A
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21
Q

what Rx can cause ARF

A

**ACE-I: **monopril, captopril, enalapril
ARB: angiotensin receptor blocker, (Diovan, Cozaar, Benicar);
NSAIDs:Indomethacin
PPI: proton pump inhibitors Prilosec, Prevacid &
Nexium (also linked to stomach cancer)

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22
Q

why would anti hypertensives cause ARF?

A

throw off autoregulation of the MD cells

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23
Q

TTP-HUS

A

thrombotic thrombocytopenic purpura–hemolytic-uremic syndrome.
can lead to ARF

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24
Q

intrinsic causes ARF

A
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25
Q

post renal causes ARF

A
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26
Q

ARF tx

A

address the underlying cause
fluids
medication
dialysis.

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27
Q

Chronic Kidney Disease causes (examples)

A

*Chronic Glomerulonephritis
*Systemic Lupus Erythematosus
*Neoplasms (MM)
*Polycystic kidney disease
*AIDS nephropathy
*Diabetic nephropathy
*Etc. (many others)

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28
Q

risk factors of chronic kidney dx

A
  • Age (≥60 years of age)
  • Smoking
  • Obesity
  • HTN: poorly controlled
  • Diabetes : 40-50% of patients with type 2 DM
  • Nephrotoxins/Drugs
  • Infections
  • Low birthweight
  • Chronic Inflammation
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29
Q

diabetic kidney dx pathogenesis

A
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30
Q

Chronic Kidney Disease diagnostic criteria
Glomerular Filtration Rate (GFR):
Urinary albumin/creatinine ratio:
Urinary albumin excretion rate:

A

Glomerular Filtration Rate (GFR): <60 ml/min/1. 73 m2
Urinary albumin/creatinine ratio: ≥ 30 mg/g
Urinary albumin excretion rate: ≥ 30 mg/day

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31
Q

Diagnosis and Classification of CKD are based on:

A

GFR and albuminuria/proteinuria

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32
Q

End-Stage Renal Disease (ESRD)
* GFR value?
* Requires what tx

A
  • GFR <15 ml/min/1.73 m2
  • Requires kidney replacement therapy (hemodialysis, transplantation)
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33
Q

GFR with age

A

decreases

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34
Q

severely decreased GFR level

A

15-29mL/min/1.73m2

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35
Q

CKD and fluid/electro balance

A

I. Fluid and electrolyte imbalance
* Dysregulation of Na+, K+ and H2O reabsorption
* Hyperkalemia
* Edema

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36
Q

CKD and hypertension

A

Hypertension
* RAS activation
* Aldosterone and catecholamine activation
* Hypervolemia

37
Q

CKD with CV and endocrine

A

III. Cardiovascular Disease
IV. Endocrine dysfunction

38
Q

CKD anemia

A

Anemia [Hb <12 g/dl (F); <13.5 g/dl (M)]
* Decreased Epo and RBC survival
* Impaired iron absorption (insufficient hepcidin),
blood loss (dialysis)
* Normocytic, normochromic anemia

39
Q

CKD and uric acid

A

uric acid) and Uremia (urea)

40
Q

CKD dyslipidemia

A
  • Dysregulated metabolism of lipid and uremic toxin-mediated lipid alterations
  • Atherosclerosis
41
Q

CKD can lead to acidosis or alklosis

A

Metabolic acidosis
* Decreased excretion of NH4+
* Decreased absorption of H+ and HCO3-

42
Q

CKD Mineral bone disorder (MBD)

A

Mineral bone disorder (MBD)
* Decreased vitamin D levels
* Dysregulation of Ca2+ and PO4-3
* Increased PTH and FGF23 levels
* Renal Osteodystrophy, secondary hyperparathyroidism
* Calciphylaxis –extraosseous calcifications
➢Blood vessels of dermis & subcutaneous fat

43
Q

CKD mineral bone disorder oral sign

A

may see browns tumros due to hyperPTH

44
Q

CKD diabetic management factors to control

A
  • Control DM
  • Control HTN
  • Control HLD
  • Diet/lifestyle modification
  • Management of other comorbidities and complications
45
Q

CKD DM control

A

HbA1 <8%

46
Q

HTN control CKD DM

A

Control HTN –BP <140/90 mm Hg
* Cardioselective beta-blocker
* Diuretics
* ACE inhibitor
* ARB
* Calcium channel blocker

47
Q

HLD control CKD DM

A

LDL <100mg/dl

48
Q

CKD oral manifestations

A

Xerostomia/dry mouth
Halitosis
Dysgeusia
Infections
Enamel defects (children)
Uremic stomatitis (rare)
Petechiae and ecchymosis
Osteodystrophy

49
Q

CKD dysguesia

A

metallic taste

50
Q

CKD oral infections

A
  • Opportunistic
  • Periodontal
  • Odontogenic
  • Salivary
51
Q

when would uremic stomatitis be seen with CKD

A

BUN >55 mg/dl

52
Q

CKD osteodystrophy

A
  • Lack of hydroxylation of 25(OH)D to 1,25(OH)2D which takes place in the kidneys
  • Causes lack of Ca+ absorption from intestines
  • Stimulates parathormone secretion and Ca+ loss from bone
  • Inhibits bone mineralization
53
Q

Osteodystrophy Causes in oral cavity

A
  • Loss of lamina dura
  • Demineralization (“ground-glass”)
  • Expansile radiolucencies (CGCG, brown tumor)
  • Wide trabeculae
  • Loss of cortication
  • Sclerosis
54
Q

compare

A
55
Q
A

ground glass- osteodystrophy

56
Q
A

ground glass osteodystrophy

57
Q

CKD dialysis modalities

A

hemodialysis and peritoneal

58
Q

hemodialysis

A
  • Arteriovenous fistula
  • Ateriovenous graft
  • Central venous catheter (special, short-term)
  • Machine filters blood
  • Heparin is typically used
  • Every 2-3 days; 3-4 hours/session
  • Risk of infectious disease –Hep B; Hep C
59
Q

hemodialysis and dental tx

A

Dental treatment planned for the
day AFTER hemodialysis

60
Q

Peritoneal dialysis

A
  • Hypertonic solution in peritoneal cavity
  • Peritoneal membrane used for exchange
  • 3-5x/day or overnight
61
Q

forms of access for dialysis

A
62
Q

Arteriovenous Fistula and Arteriovenous
Graft use may lead to:

A

difigurements

63
Q

organ transplant matching

A
  • ABO matching
  • HLA matching
64
Q

organ transplant life expectancy/ organ sources

A
  • > 5- year life expectancy
  • Can be from live (better) or deceased donor
    oRelated mismatched donor (3/6 match) is better
    than deceased donor
65
Q

contraindications to transplant

A
  • AIDS
  • Active hepatitis
66
Q

organ rejection

A
  • Activated cytotoxic T cells (direct)
  • Alloantibodies (direct)
  • Delayed type hypersensitivity –arteriosclerosis of
    transplant (indirect)
67
Q

trnasplants req what tx

A

immunsupression

68
Q

stages of immunosupp tx

A

Induction (prevent acute rejection)
Maintenance (unless identical twin)

69
Q

induction Rx

A
  • Antithymocuyte globulin
  • Alemtuzumab (anti-CD52)
70
Q

maintenance Rx
Azathioprine
Mycophenolate mofetil
Calcineurin inhibitors
Steroids
mTOR inhibitors (mTORi)
Belatacept

A

* Azathioprine- Antimetabolite
o** Inhibits DNA and/or RNA synthesis**

* Mycophenolate mofetil- Similar to azathioprine
o **Less bone marrow suppression **

  • Steroids **
    o    Low dose**, adjunct
  • Calcineurin inhibitors: Cyclosporine and Tacrolimus
    oBoth decrease production of** IL-2 mRNA and proinflammatory cytokines**
    oDiabetes and nephrotoxicity complications
  • mTOR inhibitors (mTORi): Sirolimus, Everolimus
    o**Inhibits T cell proliferation signaling **

* Belatacept
* Binds costimulatory molecules
* **T cell anergy and apoptosis **

71
Q

Important adverse effects of immunosuppression

A
  • Cytopenias (bone marrow suppression)
    ➢ Bleeding- Severe thrombocytopenia <50K
    ➢ Susceptibility to infection- Severe leukopenia/ neutropenia
    oWBC <2000
    oANC <500
  • Increased risk of developing skin and hematologic cancers
72
Q

oral adverse effects of immunosuppression

A
  • Gingival hyperplasia (cyclosporine)
  • Aphthous-like ulcers (mTORi)
73
Q

values to determine level of renal impairment and disease control

A
  • BP –Avoid arm with AV shunt when measuring BP
  • GFR
  • BUN
  • Creatinine clearance
  • Serum creatinine
  • Electrolytes
74
Q

assessing bleeding with renal pts

A
  • Patients can be at risk for both bleeding and thrombosis
  • Quantitative and qualitative platelet impairment
    ➢ Platelet count
    ➢ PT-INR
    ➢ PTT
  • Hemostatic measures as necessary
  • Be aware of signs and symptoms of thrombosis
  • Referral to a specialized center as necessary
75
Q

infection control with renal pts
* Advanced uremia →?
* Treat infections how?
* If invasive procedures in patients with stage 4 (severe) or end-stage renal disease →?
* Antibiotic prophylaxis IS NOT routinely necessary for?
* Antibiotic prophylaxis may be necessary for patients with?
* Antibiotic prophylaxis is necessary in hemodialysis patients if performing?

A
  • Advanced uremia →decreased immune function
  • Treat infections aggressively
  • If invasive procedures in patients with stage 4 (severe) or end-stage renal disease →
    consult physician about need for antibiotics
  • Antibiotic prophylaxis IS NOT routinely necessary for peritoneal dialysis
  • Antibiotic prophylaxis may be necessary for patients with a synthetic AV graft
  • Antibiotic prophylaxis is necessary in hemodialysis patients if performing incision and
    drainage
76
Q

drug effects with renal pts
* Check drug ________ mechanism
* Caution with?
* Carefully review possible_______ with current medication list when prescribing new medications
* Consult with?

A
  • Check drug excretion mechanism
  • Caution with nephrotoxic drugs (acyclovir, NSAIDs, aspirin, aminoglycosides, tetracycline)
  • Carefully review possible drug interactions with current medication list when prescribing new medications
  • Consult with patient’s physician
77
Q

preffered analgesic with renal pts

A

acetaminophen

78
Q

Acetaminophen with renal pts

A
  • Nephrotoxic at high doses
  • Increase dosing interval
    oq6h (GFR >10 but <50ml/min)
    oq8hs (GFR <10ml/mim)
79
Q

NSAIDs and renal pts

A

**AVOID **
* Except for aspirin for CVD
* Especially long-term use
* Interaction with antihypertensives
* Impairment of prostaglandin production
➢ Vasoconstriction, reduced renal perfusion

80
Q

opioids and renal pts

A

AVOID
* Risk for accumulation of toxic metabolites
* Tramadol with dose adjustment and/or increased dosing interval
* Consult with physician

81
Q

Benzodiazepines with renal pts

A

CAUTION
* Consider half-life, active metabolite
* Single dosing, consult with physician

82
Q

Acyclovir
renal pts

A
  • Increase dosing interval q8h or q12h
83
Q

Abx not req adjustment with renal pts

A

oClindamycin
oDoxycycline
oErythromycin
oMetronidazole

84
Q

Abx req adjustment with renal pts
oAmoxicillin
oCephalexin
oAzithromycin

A

oAmoxicillin –q12h or q24h
oCephalexin –q6-18h or q12-24 h
oAzithromycin –avoid if GFR <10

85
Q

antifungal agents and renal pts

A

Fluconazole
* Reduce to 50% or 25% of original dose
Nystatin –No adjustment

86
Q

Goals of pre-transplant dental clearance

A

Remove active foci of infection and limit potential foci of infection (think 6 months)
*Treat active foci of infection
oSRP
oEndodontic treatment
oRestorations
*Extract teeth with questionable (even if in your opinion minimally)/poor prognosis
*Assess caries risk and need for adjuncts (fluoride)
*Educate patient on importance of maintaining good homecare, diet and professional maintenance
Take into account patient compliance and, unfortunately, patient economics when planning treatment

87
Q

post transplant tx

A

Defer elective treatment within first 6 months post-transplant
* Emergency care only –consider specialized center

88
Q

dental maintance surveillance
* Opportunistic infections
* Toxicities/side effects of systemic treatment
* Cancer

A
  • Opportunistic infections (odontogenic, candidiasis, aspergillosis, HSV, OHL, CMV)
  • Toxicities/side effects of systemic treatment
    oAdrenal insufficiency –long-term high-dose corticosteroids
    oGingival hyperplasia - cyclosporine
    oPyogenic granuloma and OFG-like lesions - tacrolimus
    oOral ulcerations –sirolimus
  • Cancer
    oNon-melanoma skin cancer (basal cell and squamous cell carcinoma [SCCa])
    oPost-transplantation lymphoproliferative disorder (frequently EBV associated, B cell)
    oOther solid cancers including oral SCCa

MED COMP PTS (9 decks)

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