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BDS2 - Renal System > Renal Medicine 1 > Flashcards

Renal Medicine 1 Flashcards

1
Q

where are kidneys found

A
  • Round the back
  • Quite high up
  • behind muscles and ribcage
  • Hard to access
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2
Q

what is the glomerulus

A
  • Sac for collecting fluid
  • Urine flow modified
  • Purely the moving of fluid and electrolytes from artery to collecting duct
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3
Q

what do the efferent and afferent arteries control

A

filtration pressure - needs to be kept precisely
Each has little muscular traps which can squeeze shut or open if blood pressure in renal artery branch is higher then the muscle can shut off and reduce the pressure
Renin angiotensin system comes into play with these as well

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4
Q

what is an indication of disease

A

Finding cells or proteins in the urine is an indication of disease (particularly disease in the glomerulus) as these should be too large to pass through

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5
Q

if there is no ADH what problems aris

A

the urine won’t concentrate properly

Associated with diabetes insipidus - peeing a lot of abnormal urine

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6
Q

what is off balance with disease of the collecting duct

A

the composition of electrolytes will be off balance

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7
Q

what do collecting tubules modify

A

the volume and that is how we end up with amount of urine produced

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8
Q

what are the 2 types of renal failure

A

acute and chronic

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9
Q

what is polyuria

A

Production of abnormally large volumes of dilute urine

Peeing too much

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10
Q

what is dysuria

A

Painful or difficult urination

Pain on passing urine

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11
Q

what is haematuria

A

the presence of blood in urine
Passing red or blood stained urine - visible blood
Can also be microscopic - urine looks normal but when tested there are RBCs present

Should not be any blood / cells in healthy urine

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12
Q

what is proteinuria

A

the presence of abnormal quantities of protein in the urine, which may indicate damage to the kidneys
Protein should not be able to pass through the holes in the glomerulus - Inflammation makes things more leaky and likely to escape

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13
Q

what is uraemia

A

a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys
Waste products that are meant to be excreted are not excreted and accumulate in the blood

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14
Q

how can you measure renal function

A

• Serum urea
○ Also rises with dehydration
§ Urea levels can increase if there is less water to dilute it
○ Urea levels remain relatively constant in the body but not the best guide as there are other reasons that the levels can change other than renal disease

• Serum creatinine
○ Good general guide to renal function
○ Usually a relatively low level in the body
○ Good measure of kidney function over time?

• 24hour urine collection
○ Creatinine clearance - best measure

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15
Q

what is included in renal failure

A
  • Loss of renal excretory function
  • Loss of water and electrolyte balance

• Loss of acid base balance
○ Losing hydrogen ions etc

• Loss of renal endocrine function - hormone roles as well
○ Erythropoietin § Controls ability to make red blood cells § Kidneys not functioning then they won’t be making new RBC - potential for anaemia
○ Calcium metabolism § Something to do with production or metabolism of vitamin D § No normal calcium metabolism § Also problems with parathyroid
○ Renin secretion

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16
Q

what is acute renal failure

A

○ Rapid loss of renal function
○ Usually over hours or days
§ Happens suddenly - go from healthy to poor function speedily
○ Can happen due to an infection or a trauma to the kidneys or sometimes due to medicines
○ Traumatic accident
§ Lots of injury to the muscles
§ Causes muscle proteins to be broken down in the muscles and taken to the bloodstream
§ Go to the kidneys but there are so many they swamp the glomerulus
§ Becomes blocked up so cannot filter the plasma

Patients will need treatment until the kidneys recover

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17
Q

what is chronic renal failure

A

○ Gradual loss of renal function
§ Can take 10-20 years to develop but can be shorter periods of time in some cases
○ Usually over many years

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18
Q

what are the 3 main areas of renal failure

A

pre-renal
renal
post renal

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19
Q

what are the causes of pre-renal failure

A

Hypoperfusion of the kidney - kidney cells do not have enough oxygen, not metabolised properly - happens with significant drop in blood pressure either due to a big bleed or when a patient has been resuscitated and have a low blood pressure for a few hours etc
§ Shock □ Too low for normal cardia output to body tissues
§ Renal artery or aorta disease □ Heart prioritises sending blood to the heart and brain whereas the kidneys are not a priority □ Aneurysm - artery burst so the blood flow to kidneys reduced

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20
Q

what are the causes of renal failure

A

○ Chronic disease § Renal diabetic disease is a big cause of failure
○ Drug damage
○ Trauma § Just unfortunate if this happens to you
○ Rhabdomyolysis § Long term problems § Serious syndrome due to a direct or indirect muscle injury ie patient is squashed in a car accident or hurt from a long fall § It results from the death of muscle fibres and release of their contents into the bloodstream
This means the kidneys cannot remove waste and concentrated urine

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21
Q

what are the causes of post renal failure

A

○ Renal outflow obstruction
§ Cannot pee urine out so cannot produce any more
Stones / prostate blockage of the urinary tract

22
Q

define prerenal failure

A

sudden and severe drop in blood pressure (shock) or interruption of blood flow to the kidneys from severe injury or illness

23
Q

define renal failure

A

direct damage to the kidneys by inflammation, toxins, drugs, infection or reduced blood supply

24
Q

define post renal failure

A

sudden obstruction of urine flow due to enlarged prostate, kidney stones, bladder tumour or injury

25
Q

what happens in acute renal failure in lots of detail

A

• Rapid loss of renal function
○ Creatinine > 200μmol § Normal creatinine is around 80μmol
○ Anuric (no urine passing) initially with volume overload
§ Ankle oedema or sacral oedema □ Not losing urine, extra fluid so the urine accumulates
§ Pulmonary oedema and breathlessness
§ Raised jugular venous pressure (JVP)
§ Weight gain = Kg per L

○ Gradually progresses to polyuria § Healing restores filtration before concentration ability □ Lose a lot of fluid suddenly - might become dehydrated □ Eventually concentration ability will come back

• Development of hyperkalaemia (high potassium - problem)
○ Can lead to cardiac arrest

• Development of uraemia and acidosis 
○ High urea
○ Low bicarbonate 
○ Increased respiratory excretion of CO2 
	§ Raised respiratory rate

• Usually a pre-renal cause
Fall in blood pressure associated

26
Q

is acute renal failure reversilbe

A

usually yes with time

27
Q

what is the treatment for acute renal failure

A

• Renal support until recover
○ Dialysis § Artificial replacement of some aspects of renal function
○ Nutrition

28
Q

what is involved in primary chronic renal failure

A

Primary (rare)
○ Glomerulonephritis
§ Acute inflammation of the kidney, typically caused by an immune response
○ Polycystic kidney disease
§ Cysts between the kidneys, They get bigger and bigger and squash the kidney tissue so the kidneys are not functioning

29
Q

what is involved in secondary chronic renal failure

A 
Secondary - range of different things as part of other disease problems
○ Diabetes (30%)
○ Hypertension (20%)
○ Drug therapy
○ Vasculitis 
○ Renal artery disease / aorta disease
30
Q

what is glomerulonephritis

A

acute inflammation of the kidney, typically caused by an immune response.

• Haematuria / proteinuria 
○ Otherwise healthy individual
• Gradual progression to 
○ Hypertension
○ Chronic renal failure
31
Q

what is nephrotic syndrome

A

loss of protein at a very big level

• Complication of glomerulonephritis
○ Excessive loss of protein in the urine - >3g in 24hours
§ Hypoalbuminemia □ is a medical sign in which the level of albumin in the blood is low
○ Loss of plasma oncotic pressure
○ Tissue swelling (oedema)

• Hypercoagulable state
○ Loss of clotting factors - AT3 deficiency
○ Dehydration raises other coagulation factor concentrations

32
Q

how does drugs affect renal disease

A

• NSAIDs
○ Inhibit glomerular blood flow
○ Cause interstitial nephritis
○ Avoid in renal disease if possible

• Nephrotoxic drugs
○ Cyclosporin

33
Q

what is renal vascular disease

A

• Reduced blood flow to the kidney
○ Atheroma of renal artery / aorta § Atherosclerosis of the aorta is most common § Renal artery main branch after the neck
○ Hypertension - narrowing of renal artery

• Microangiopathy
Damage to blood vessels at a microscopic level caused by immune system
○ Immune reaction causing small blood vessel damage, RBC damage and thrombosis
§ E Coli 0157 - associated with animals

34
Q

what is renal artery disease

A

the junction of the artery in the kidney is 90 degress
causes damage and builds up
prone to atherosclerosis - causes problems with renal blood flow and leads to hypertension

35
Q

what happens in immune mediated renal damage

A

Less common but exists

• Multiple myeloma
○ Tumour of the plasma cells
§ B cells make antibodies - make copies of themselves to deal with infection
§ Plasma cells proliferate without control - so there is lots and lots of antibodies
○ Excess light chain production ‘clogs’ kidney
§ Tubular nephritis results
§ Affects bones and kidneys □ Come across bone disease more often

• Goodpasture’s syndrome - wrong genetic makeup
○ Anti-glomerular basement membrane antibody (anti-gbm)
§ Come across infection to create antibody that matches the glomerular basement membrane
§ Damages kidney

• Vasculitis
○ SLE and variants
○ Any vascular disorders tends to clog up and shut down the kidneys
○ When these happen in the kidney there are problems

36
Q

what causes polycystic kidney disease

A 
Gene mutation (PKD1,2,3)
Inherited (AD or AR) or spontaneous
37
Q

what is polycystic kidney disease

A

Multiple cysts in the renal parenchyma
○ Enlarged kidney
○ Progressive destruction of normal kidney
○ Gradual renal failure

38
Q

when does end stage renal disease occur

A
  • eGFR < 15ml/min
    ○ Estimated glomerular filtration rate - usually normal is > 60ml/min?
  • Creatinine 800-1000μmol/L
    ○ No useful secretion (Still an acceptable measurement but using the eGFR is used more)
39
Q

what does the time taken for end stage renal disease depend on

A

underlying cause

modifying factors

40
Q

what is stage 1 kidney damage

A

normal / minimal kidney damage with normal GFR
GFR = 90+
protein or albumin in urine are high, cells or casts seen in urine

41
Q

what is stage 2 kidney damage

A

mild decrease in GFR

GFR = 60-89

42
Q

what is grade 3 kidney damage

A

moderate decrease in GFR

GFR = 30-59

43
Q

what is grade 4 kidney damage

A

severe decrease in GFR

GFR = 15-29

44
Q

what is grade 5 kidney damage

A

kidney failure

GFR < 15

45
Q

how is chronic renal failure managed

A 
• Reduce the rate of decline 
○ Eliminate nephrotoxic drugs
○ Control hypertension
○ Control diabetes
○ Control vasculitic disease § Steroids / other immune suppressant drugs

• Control fluid balance
○ Restrict fluid intake
○ Restrict salt, potassium, protein

• Correct deficiencies
○ Anaemia (erythropoietin)
○ Calcium (vitamin D)

• Remove outflow obstruction
○ Renal stones (calculi)
○ Prostate enlargement

• Treat infection
○ Chronic renal system infection

46
Q

what are the signs of chronic renal failure

A 
○ Anaemia 
○ Hypertension (Caused by and causes)
○ Renal bone disease - Resorption of bones
	§ Low Ca, high PO4
	§ Hyperparathyroidism 
	§ Osteomalacia
47
Q

what are the symptoms of chronic renal failure

A

Not specific so it isn’t easy for the patient to tell you about, Happens so gradually people put the changes down to age

○ Insidious 
○ Polyuria 
○ Nocturia - is a condition in which you wake up during the night because you have to urinate
○ Tired and weak 
○ Nausea
48
Q

what does renal replacement therapy do

A

• Replaces functions of the kidney
• But not a cure for renal disease
○ Always have a deficit because your own kidneys are not working

49
Q

what is important to know for dentistry with regards to renal disease

A
  • Few direct oral problems
  • General health may dictate treatment timing

• Care with prescribing - main issues
○ Check all drugs with renal physician
○ Avoid NSAIDs, some tetracyclines
○ Reduce dose of most others

• Oral opportunistic infections
○ Fungal and viral infections / reactivations
○ Prone to post-op infections

• Dry mouth & taste disturbance
○ Fluid restriction and electrolyte disturbance

• Bleeding tendencies
○ Platelet dysfunction

• Renal osteodystrophy
○ Lamina dura lost
○ Bone radiolucency - Secondary hyperparathyroidism increases osteoclast activity

50
Q

how does chronic renal failure affect dentistry

A

• Growth may be slow in children ○ Tooth eruption may be delayed
• Secondary effects of anaemia
○ Oral ulceration
○ ‘dysesthesias’ - painful mucosa and tongue
• White patches
○ Uraemic stomatitis

BDS2 - Renal System (3 decks)

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