Renal (Exam 3) Flashcards
1
Q
Percentage of the body weight that is water?
A
60% TBW
2
Q
2 components of ECF
A
- ISF
- Plasma
3
Q
Name the body fluids that is more immediately altered by kidneys
A
ECF
4
Q
What mediates Osmolar homeostasis?
A
- Osmolarity sensors in anterior hypothalamus
5
Q
Name (3) actions of Osmolar Homeostasis
A
- Stimulates Thirst
- Causes Pituitary Releases of Vasopressin (ADH)
- Cardiac Atria releases ANP–> acts on kidneys to release Na+/H20 and promote excretion.
6
Q
Volume homeostasis is mediated by _____________.
A
Juxtaglomerular apparatus.
7
Q
How does the Juxtaglomerular appartatus mediated volume homeostasis?
A
- JGA senses changes in volume
- ↓Vol @ JGA triggers–> RASS→Na+/H20 reabsorption
8
Q
Normal Sodium Level
A
135-145
9
Q
Sodium Levels that are acceptable for Surgery
A
125-155
10
Q
Underlying causes for Abnormal Sodium levels
A
- hypovolemia
- Euvolemic
- Hypervolemic
11
Q
Na/H20 loss, diuretics, GI loss, burns and trauma cause __________.
A
Hypovolemia
12
Q
Salt restriction, endocrine related – hypothyroid and SIADH all cause ________
A
Euvolemia
13
Q
What percentage of hospitalize patients are hyponatremic?
A
- 15%
14
Q
Over fluid-resuscitation and ↑endogenous vasopressin are 2 common cause of __________ in the hospital.
A
- hyponatremia
15
Q
Asymptomatic, headaches, nausea, vomiting, fatique, confusion, muscle cramps and depressed reflexes are all symptoms of a Sodium level of ____ - ______ mEq/L.
A
- 130-135 mEq/L
16
Q
Malaise, unsteadiness, headache, nausea, vomiting, fatique, confussion and muscle cramps are all symptoms of a Sodium level of ___ - _____ mEq/L
A
- Sodium 120-130 mEq/L
17
Q
Headache, restlessness, lethargy, seizures, brain-stem herniation, respiratory arrest and death are all symptoms of a Sodium level < _______ mEq/L.
A
< 120 mEq/L
18
Q
The most severe consequences of hyponatremia include….
A
- Seizures
- coma
- death
19
Q
You can treat ______ by treating underlying conditions (volume status), electrolyte drinks, normal saline, diuretics and hypertonic saline.
A
Hyponatremia
20
Q
Hypertonic Saline/3% NaCl is given at a rate of ___ ml/hr over ___ hours.
A
- 80 ml/hr over 15 hours
21
Q
Maximal amount of Na correction is ___ mEq/L/hr.
A
1.5 mEq/L/hr
22
Q
________________ syndrome is the rapid correction of sodium, > 6mEq in 24 hours.
A
- Osmotic Demyelination Syndrome.
23
Q
Consequences of Osmotic Demyelination Syndrome
A
- Permenant Neuro damage
24
Q
Hyponatremic Seizures are treated with _____ ml/kg of 3% over ____ minutes until seizure has resolved.
A
- 3-5 ml/kg
- 30 minutes
25
How often should you check NA levels while replacing?
* Every 4 hours
26
Excessive evaporation, Poor oral intake, overcorrection of hyponatremia, Diabetes Insipidus, GI loss and Excessive sodium bicarb are all causes of ___________________
hypernatremia
27
Orthostasis, Restlessness, lethargy, tremor/muscle twitching/spasticity, seizures, and death are symptoms of ______________.
* Hypernatremia
28
Treatment of Hypervolemia
* Hypovolemia: Normal Saline
* Euvolemic: water replacement (po or D5W)
* **Hypervolemic: diuretics**
29
VS, UOP, Turgor and CVP are (4) ways to assess _______ ________.
volume status
30
Na levels should be reduced at a rate of <____ mmol/L/hr and < ____ mol/L/day to avoid cerebral edema, seizures and neurologic damage.
* ≤0.5 mmol/L/hr,
* ≤ 10 mmol/L per day
31
Normal Potassium Levels
3.5 - 5.5
32
____ percentage of potassium is found in the ECF?
Serum Potassium reflects ________ potassium regulation more than total body potassium.
* < 1.5%
* transmembrane
33
Name the relationship between Aldosterone and Potassium
↑Aldosterone = ↓Potassium
34
In renal _______, potassium excretion declines and excretion shifts towards ____ system
* failure
* GI system
35
Low PO intake, Renal Loss, GI loss, Intracellular shifts, DKA, HCTZ, and Excessive Licorice are all common causes of _____________.
* Hypokalemia
36
(3) Major Causes of ________ are renal loss, GI loss and transcellular shifts
hypokalemia
37
____can cause muscle weakness/cramps, illeus, dysrhthmias and U-waves
Hypokalemia
38
Best ways to correct Hypokalemia is to treat _________ causes, ____> IV replacement and ___-____ mEq/L/hr IV
* Undelying causes
* PO > IV
* 10-20 mEq/L/hr IV
39
10 mEq IV K increased Serum K+ by _____ mmol/L
0.1
40
Excessive insuline, beta blockers, Bicarb, hyperventilation and diuretics should all be avoided in patient's with __________.
Hypokalemia
41
The following are all causes of _________:
1. Renal Failure
2. Hypoaldosteronism
3. Drugs that inhibit RASS
4. Drugs that inhibit K excretion
5. Depolarizing NMB (Succs)
6. Acidosis (Respiratory/Metabolic)
7. Cell death (trauma/tourniquet)
8. Massive blood transfusion
Hyperkalemia
42
____ can cause malaise, and upset stomache chronically, while acute can cause skeletal muscle paralysis, decreased fine motor movements and cardiac dysrhythmias.
Hyperkalemia
43
EKG progressionof Hyperkalemia
* peaked T wave (1)
* P wave disappearance (2)
* prolonged QRS complex (3)
* sine waves (4)
* asystole (5)
44
Dialyze (24 hrs prior to surgery), Calcium, hyperventilation, insulin w/glucose, Bicarb loop diuretics and Kayexalate are all treatments for ________________.
Hyperkalemia
45
_________ is the 1st initial treatment of hyperkalemia
Calcium
46
______ is the fastest treatment for Hyperkalcemia.
Hyperventilation
47
Hyperventilation corrects pH: ↑pH by 0.1, ↓K+ by ______ mmol/L
*
* 0.4-1.5 mmol/L
48
Succinycholine, hypovolemia, LR, and Potassium containing IV fluids should all be avoid with _________.
hyperkalemia
49
___% of calcium is in the ECF and ____ % of calcium is in the bones
* 1% in ECF
* 99% in bones
50
Normal iCal levels
1.2 - 1.38 mmol/L
51
____and ___ can affect Ionized Calcium levels
* albumin
* pH
52
Parathyroid hormones, Vitamin D and Calcitonin are hormones that regulate _________.
Calcium
53
Parathyroid Hormone increases ____ absorption, Renal reabsorption and _____ absorption of calcium
* GI
* Renal
* bone
54
Vitamin D augments_________ Ca++ absorption.
* intestinal
55
Calcitonin _____bone reabsorption of Calcium
inhibits
56
↑ Parathyroid hormone (PTH) secretion, magnesium deficiency, low Vitamin D, renal failure and massive Blood transfusion are all common causes of ___________ .
Hypocalcemia
57
Majority of patients with hypercalcemia have ______- parathyroid or ____________.
* hyper-parathyroid: Cal <11
* cancer: Cal >13
58
Vitamin D intoxication, Milk-alkali syndrome, and Granulomatous disease are all less common causes of ______________ .
Hypercalcemia
59
Confusion, lethargy, hypotonia/↓DTR, abd pain, N/V, short QT and hypercalciuria and nephrolithias area all signs/symptoms of ____________ .
Hypercalcemia
60
Parasthesias, irritability, HoTN, seizures, myocardial depression, Prolonged Qt and Post-Parathyroidectomy-- lanyngospasm are signs and symptoms of ____________ .
hypocalcemia
61
Low dietary intake or absorption and renal wasting are (2) Causes of _____.
Hypo-magnesium
62
Muscle weakness or excitation, seizures, and ventricular dysrhythias are all symptoms of ________ .
hypomagnesium
63
Hypomagnesium is given in _____ infusion for less severe symptoms and ___ grams Mag Sulfate for Torsades/seizures
Depends on degress of severity
* slow infusions for less severe
* Torsades/seizures --> 2Gr Mag Sulfate
64
____ is very uncommon and is generally due to overtreatment.
Hypermagnesium
65
Name (2) disease processes that are at risk of hypermagnesium
* Pre-eclampsia/Eclampsia
* Pheochromocytoma
66
Lethargy, N/V, and flushing are all symptoms of Hypermagnesium
___ - ___ mEq/L
4 -5 mEq/L
67
HoTN, and decreased DTR are all symptoms of Hypermagnesium
>__ mEq/L
* 6
68
Paralysis, apnea, heartblocks and cardiac arrest are all signs of Hypermagnesium
>____ mEq/L
10
69
Name (3) treatments for Hypermagnesium
1. Diuresis
2. IV calcium
3. Dialysis
70
Kidneys are located ________ btw T12 -L4. Right kidney is slightly _____ to left to accommodate liver.
* Retroperitoneal
* caudal
71
What is the primary Strucural/Function Unit of the Kidney?
* Nephron
72
How many nephrons does each kidney have?
1 Million
73
Glomerulus, bowman capsule, proximal tubule, loop of henles, distal tubule and collecting ducts are all part of the ____________ .
Nephron
74
Each kidney receives ___ % of the CO, which amounts to ___ - ____ L/min of blood.
* 20%
* 1-1.25 L/min
75
The Outer layer/Cortex of the kidney receives ___ - ____ % of the blood flow to the kidneys.
* 85-90%
76
The ____ ___ _____ is the most vulnerable part of the kidney to HoTN.
* Loop of Henle
77
Primary Functions of the ______ :
* Regulate EC volume, osmolarity, composition
* Regulate BP
* Excrete toxins/metabolites
* maintain acid/base balance
* Produce hormones
* Blood Glucose hemostasis
Kidney
78
Renin, Erythropoietin, Calcitriol and Prostoglandins are homones produced by the _________.
Kidney
79
Name (3) Renal Functional Labs
* Glomerular Filtration Rate
* Creatine Clearnace
* Serum Creatine
80
Glomerular Filtration Rate (GFR) normal
125-140 mL/min
81
The best way to measure renal function time and is heavility influenced by hydration is the ___________ .
GFR
82
Creatine Clearance Normal
* 110-140 mL/min
* 24 hour urine test
83
_____ ____ is the most reliable measure of GFR . _ is freely filtered and not reabsorbed.
* Creatine Clearance
* Creatine
84
Serum Creatine normal
* 0.6 - 1.3 mg/dL
* correlates with muscle mass
85
______ __ can be influenced by high protein diet, supplements and muscle breakdown. Need to have a baseline for acute monitoring and is inversely related to GFR
Serum Creatine
86
What happens to the GFR if you double Serum Creatine?
drops GFR by 50%
87
Blood Urea Nitrogen normal
* 10-20 mg/dL
88
Urea Nitrogen is ______ into blood and is affected by ____ and IV volume.
* reabsorbed
* diet
89
What does a low BUN mean?
* malnurished
* volume diluted
90
↑protein diet, dehydration, GI bleed, trauma, and muscle wasting are all causes of _______ _______.
High BUN
91
BUN: Creatine ratio normal
* 10:1
92
What does a BUN:Creatine ratio measure?
Hydration status
93
Proteinuria normal
* <150 mg/dL
94
Proteinuria >750mg/dL indicates
* Glomerular injury
* UTI
95
Specific Gravity Normal
* 1.001 - 1.035
96
This lab values compares 1 mL urine to 1 mL distilles water and measure the ability to concentrate urine.
Specific Gravity
97
Edema, rales, orthostatic pressure changes, ↓BE, ↑Lactate and drop in UOP can indicate a change in _____ - ______ status.
Renal-Volume Status
98
Describe a normal UOP
* 30 mL/hr
* 0.5-1 ml/kg/hr
99
Define Oliguria
* <500ml in 24 hours
100
Ultrasound of IVC, CVP, PAP, LAP, PCWP, PAP, and SVV can all monitor ___________ __________
Volume status
101
What does percentage (%) of IVC collapse indicates fluid deficit?
* >50%
* consider passive leg raise to determine fluid responsiveness
102
Failure to excrete nitrogenous waste products or maintain fluid/electrolyte homeostatis with deteriation over hours to days is the definition of _________________ .
Acute Kidney Injury
103
AKI effects ________% of hospitalizations pts and ________% ICU patients.
* 20%
* 50%
104
Hypotension/hypovolemia and nephrotoxins are (2) main causes of ______________.
Acute Kidney Injury
105
_____ is the buildup of nitrogenous products such as urea and creatine and is a hallmark of AKI.
Azotemia
106
Mortality rate of AKI w/ Multi-System Organ Failure requiring dialysis
* >50% mortality
107
Pre-existing renal disease, advance age, CHF, PVD, Diabetes, Sepsis, jaundice, major operative procedures, and IV contrast are Risk Factors of _________.
Acute Kidney Injury
108
AKI Diagnostic Criteria
* ↑SCr by ___ mg/dL within 48 h
* ↑SCr by ____ within 7 days
* ↓Creatinine clearance by ___%
* Abrupt oliguria (although not always seen in AKI)
* 0.3 mg/dL
* 50%
* 50%
109
Asymptomatic (initially), malaise, HoTN, hypovolemic or hypervolemic are all physical symptoms of ________________ .
Acute Kidney Injury
110
Hemorrhage, GI fluid loss, trauma, surgery, burns, cardiogenic shock, sepsis, aortic clamping and thromboembolism are all causes of _______Azotemia.
Pre-Renal Azotemia
111
Acute glomerulonephritis, vasculitis, intestinal nephritis, ATN, contrast dye, nephrotoxic drugs, and myoglobinuria are all causes of _________ Azotemia.
Renal Azotemia
112
Nephrolithialasis, BPH, Clot retention, and bladder carcinoma are all causes of ________ Azotemia.
Postrenal Azotemia
113
Name the most common form of AKI
Pre-renal azotemia
114
_______ accounts for 1/2 of hospital-acquired AKI cases
* pre-renal azotemia
115
Fluids, mannitol, diuretics, maintaining MAP and use of pressors to maintain Renal Blood Flow is the treatment for ____________ Azotemia.
Pre-Renal Azotemia
116
Lab work that can indicate a Pre-Renal AKI
* BUN: Cr >20:1
117
Name the most common cause of ATN (acute tubular necrosis)
* Untreated Pre-Renal AKI
118
What type of Renal disease is Renal Azotemia?
Intrinsic renal disease
119
Is Renal azotemia reversible?
* Yes.
* Just not as reversible as Pre-Renal
120
Following Labwork indicates:
* ↓GFR(late sx)
* ↓urea reabsorption in prox tubule →↓BUN
* ↓Creatinine filtration→↑blood creatinine
* BUN:Cr often < 15
Renal Azotemia
121
Outflow obstruction and ↑Nephron tubular hydrostatic pressure are causes of ______________ .
Post-Renal Azotemia
122
Treatment for Post-Renal Azotemia
* Remove obstruction if possible
* Persistent obstruction damages the tubular epithelium
123
Neurological complications of ____ are related to protein/amino acid buildup in blood:
Uremic Encaphalopathy
* Mobility disorders
* neurapthise
* myopathies
* seizures
* strokes
Acute Kidney Injury
124
Systemic HTN, Left Ventricular hypertrophy, CHF, pulmonary edema, uremeic cardiomyopathy and arrythmias are cardiovascular Complication of ________.
Acute Kidney Injury
125
Anemia from ↓ EPO production, ↓ red cell production, ↓ red cell survival, Platelet dysfunction , and vWF disrupted by urmeia are Hemological Complications of _________ .
Acute Kidney Injury
126
Hyperkalemia, metabolic acidosis, malnutrition, hypoalbuminemia, and hyperparathyroidism are
____________ Complications of AKI.
Metabolic
127
Anesthetic Implications of an AKI
* Correct fluid, electrolyte, acid/base status
* Volume -- NS is prefered
* careful with colloids
* Maintain MAP
* Vasopressin
* Sodium Bicarb
128
Reason to give Prophylatic Sodium Bicarb to an AKI pt before anesthesia
* decreases formation of free-radicals
* Prevents Acute Tubular Necrosis from causing renal failure
129
Reason Vasopressin is pressor of choice for AKI patients because it constricts _____ arterioles and mantains ____.
* Efferent arterioles
* Maintains RBF
130
In anesthesia for ________ patients, consideration for:
* low threshold for hemodynamic montoring
* Prefer preop dialysis
* Recent Labs (K) within 1 hour of surgery
* POC equipment available
* Tailor drug choices
* avoid drugs with active metabolites that ↓RBF and renal toxins
Kidney Patients
131
Name the (2) Leading causes of CKD
* Diabetes
* hypertension
132
Is CKD reversible?
* NO
* It is also progressive
133
GFR decreases ____ per decade starting from age 20
* 10
134
Stages of CKD:
Kidney damage with normal or increased GFR
* Stage 1
* GFR >90
135
Stages of CKD:
Kidney Damage with mildly decreased GFR
* Stage 2
* GFR 60-89
136
Stages of CKD:
Moderately decreased GFR
* Stage 3
* GFR 30-59
137
CKD Stage:
Severely decreased GFR
* Stage 4
* GRF 15-29
138
CKD Stage:
Kidney Failure
* Stage 5
* GFR <15
139
CKD can cause Systemic HTN by causing _______ of sodium and water and activation of ________.
* retention
* activation of RAAS
140
______diuretics are the 1st line Treatment of Cardiovvascular effects of CKD, followed by _____ and ARBs
* 1st line: Thiazide Diuretics
* ACE-I/ARB
141
CKD in combination with these (2) medications can cause:
* ↓systemic BP and glomerular pressure
* ↓proteinuria by reducing glomerular hyperfiltration
* ↓glomerulosclerosis
* ACE
* ARBs
142
When should ARBs and ACE-I be held before surgery?
* 24 hours
143
What medications might need to be given if ACE-I or ARB were taken prior to surgery?
* Vasopressin
* NE
* EPI
144
What population are high risk for silent MI
* Womens
* Diabetics
145
CKD Cardiovascular Effects: Dyslipidemia
* Triglycerides > 500
* LDL > 100
* Predisposed to Silent MI
146
CKD Hematolgic Effects: Anemia
* Responsive to exogenous erythropoietin -- target Hgb 10
* Platelet dysfunction
147
What (2) conditions are associated with blood transfusion
* Acidosis
* Hyperkalemia
148
Volume overload, severe hyperkalemia, metabolic acidosis, symptomatic uremia and failure to clear medications are indications to consider ______________.
Dialysis
149
What is the most common SE of HD?
* HoTN
150
What is the leading cause of death in dialysis patients?
Infection
151
Is HD or PD more effective?
* HD
152
Anesthesia concerns for ________ patients:
* Access stability
* Body weight pre/post dialysis
* well-controlled BP
* Glucose Management
* Aspiration precautions
* Pressors
* Uremic bleeding
* Dialysis
153
Treatment for Uremic Bleeding
* Cryo. FVIII, vWF
* Desmopressin
154
Desmopressin peaks in _ - __ hours; lasts __-__ hours and can cause tachyphylaxis.
* Peak 2-4 h
* lasts 6-8 hours
* Tachyphylaxis
155
Anesthesia and CKD
* Many anesthetic agents are lipid soluble
* Reabsorbed by renal tubular cell
* Lean towards agents not dependent on renal elimination
* Avoid active metabolites
156
Name (2) Drugs to avoid with CKD patients due to active metabolites
* Morphine
* Demerol
157
Why should we avoid lipid soluble medications in CKD patients?
* Elimination is unchanged in urine
* Prolonged DOA
158
Name (4) types of drugs that should be Renal dosed based on GFR
* Thiazide diuretics
* Loop Diuretics
* Digoxin
* Antibiotics
159
Morphine is ___% cleared through urine and has 2 metabolites ( morphine - __ glucuronide and morphine -___ glucuronide)
* 40%
* morphine -3 glucuronide and morphine -6 glucuronide
* Can cause life-threatening respiratory depression
160
Noremeperidone is an active metabolite of ________ than has analgesis and CNS effects and has a __________ half-life.
* Demerol
* longer
161
The following are PreOperative Concerns for ____ patients.
* K+ < 5.5 mEq/L on elective surgery
* Dialysis pts should be dialyzed within 24 h preceding elective surgery
* Aspiration prophylaxis, especially in DM --- Give high dose Roc for RSI
* Anesthesia & surgery decrease RBF & GFR
Blood loss activates baroreceptors→↑SNS outflow.
Catecholamines activate α1-Rs→↑afferent arteriole constriction→↓RBF
* Longer periods of hypotension (cross-clamping, hemorrhage, sepsis) →↓RBF
Renal Patients
