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Pathophysiology > Renal Part 2 > Flashcards

Renal Part 2 Flashcards

1
Q

what are normal levels of BUN and creatinine (SCr)?

A

BUN: 7-20
Cr: 07-1.2

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2
Q

BUN:Cr for pre-renal, intra-renal, post-renal

A

pre-renal: >20:1
intra-renal: 10-20:1
post-renal: 10-20:1

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3
Q

ATN is < __:__ (BUN:SCr)

A

20:1

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4
Q

BUN:Cr mechanism: pre-renal

A

BUN reabsorption is increased. BUN is disproportionately elevated relative to creatinine in serum. Dehydration or hypoperfusion is suspected.

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5
Q

BUN:Cr mechanism: intra-renal

A

Renal damage causes reduced reabsorption of BUN, therefore lowering the BUN:Cr ratio.

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6
Q

BUN:Cr mechanism: post-renal

A

Normal range. Can also be postrenal disease. BUN reabsorption is within normal limits.

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7
Q

ARF:
Sudden loss of renal function over ______,
decreasing ____,
Rise in serum creatinine by at least ____

A

hours/days/weeks
decreasing GFR
0.5 mg/dL over patient’s baseline

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8
Q

anuric vs oliguric vs nonoliguric

A

Anuric: urine output < 50 mL/day
Oliguric: urine output < 400 mL/day
Nonoliguric: urine output > 400 mL/day

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9
Q

ARF pts usually have symptoms of _____ and _____ ( in acute reduction urine output)

A

peripheral edema, shortness of breath

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10
Q

causes of ARF: pre-renal

A

pre-renal: decrease in blood flow without ischemic injury (prerenal azotemia)

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11
Q

causes of ARF: intra-renal

A

ischemic, toxic, or obstructive tubular injury (you can have a post-renal source that goes on to cause intrinsic renal failure)

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12
Q

causes of ARF: post-renal

A

obstruction of urinary tract outflow (examples- kidney stones, tumors, strictures in ureters, etc.)

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13
Q

most common cause of ARF. is this reversible

A

pre-renal failure (aka azotemia)

YES reversible!

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14
Q

what type of drugs can cause decreased renal perfusion?

A

endotoxins, cyclosporine, epinephrine, high doses of dopamine.

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15
Q

ACEs and ARBs are _______ _____ in pts with HTN and DM. however, if used with ______, can cause ____ ______

A

renal protective in pts with HTN and DM. However, if ACEI or ARBs are used with diuretics, they can cause prerenal failure.

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16
Q

ACEs and ARBs are renal protective. how?

A

reduces the effect of angiotensin (a renal vasoconstrictor) on the blood flow

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17
Q

NSAIDs cause reduced renal blood flow, how?

A

NSAIDs can reduce renal blood flow b/c they block with vasodilation properties of prostaglandins

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18
Q

what do the labs show for pre-renal failure?

A
  • decreased GFR
  • Increased creatinine (but BUN increases MORE, so…)
  • elevation in the ratio of BUN to creatinine from a normal value of 10:1 to a ratio of greater than 20:1
  • FeNA <1%
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19
Q

Intrinsic Renal Failure: caused by _____ which results from conditions that cause ….

A

ATN: Results from conditions that cause injury to structures (tubules) within the kidney (ischemia, injury)

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20
Q

part of ATN: Tubulointerstitial disorder: destruction of ____ _____ _____ with acute suppression of renal function.

A

Tubulointerstitial disorder

destruction of tubular epithelial cells with acute suppression of renal function.

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21
Q

ATN can be caused by…

A

acute tubular damage d/t ischemia, sepsis, nephrotoxic effects of drugs, tubular obstruction, toxins from massive infections.

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22
Q

ATN: the GFR does or does not improve with the restoration of renal blood flow in ARF caused by ischemic ATN? what about creatinine?

A

does NOT

creatinine will be restored to normal

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23
Q

ATN caused by intratubular obstruction is most often caused by what 4 things?

A

ATN caused by intratubular obstruction is most often caused by multiple myeloma light chains, excess uric acid, myoglobin, or hemoglobin in the urine

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24
Q

3 stages of ATN?

A
  1. onset or initiation phase
  2. maintenance phase
  3. recovery phase
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25
Q

what is normal GFR?

A

about 90

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26
Q

majority of intrinsic renal failure is caused by what? at what percent ?

A

ATN 85%

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27
Q

*intrinsic- theyll have normal range BUN/Creatine 10-20 but…

A

creatinine will be ABNORMAL

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28
Q

ATN stage 1: onset or initiation phase: how long does it last? from when to when?

A

lasts hours or days, time of the onset of precipitating event until tubular injury occurs

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29
Q

ATN stage 2: maintenance phase: what is the key factor of this stage?

A

marked decrease in GFR!

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30
Q

ATN stage 3: recovery phase: what happens here?

A

when renal tissue repair takes place. Onset is heralded by gradual increase in urine output and a fall in serum creatinine

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31
Q

***pre-renal vs ATN: urine osmolality

A

pre-renal: >500

ATN: <350

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32
Q

***pre-renal vs ATN: urine sodium

A

pre-renal: <20

ATN: <40

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33
Q

***pre-renal vs ATN: FENa

A

pre-renal: <1

ATN: >2

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34
Q

***pre-renal vs ATN: BUN:Cr

A

pre-renal: >20

ATN: <20

35
Q

***pre-renal vs ATN: urine sediment

A

pre-renal: bland, nonspecific

ATN: muddy brown granular casts

36
Q

Risk of Contrast-induced-neuropathy (kinda weeds…)

A 
Score	Risk of CIN	Risk of Dialysis
  0-5	      7.5%		0.04%
 6-10	      14.0%		0.12%
11-16	      26.1%		1.09%
 > 16	      57.3%		12.6%
37
Q

3 ways to reduce risk of ARF with imaging

A
  1. Hydration with IV normal saline 12 hours before and after procedure
  2. Administering acetylcysteine (Mucomyst®) before/after procedure
  3. Discontinuing Metformin prior to procedure (if possible) and held for 48 hours
38
Q

most common underlying problem for post-renal failure

A

BPH

39
Q

post-renal failure, can be caused by ____ _____ ____ or _____ _____ ______

A

can be caused by bilateral ureteral obstruction (unilateral if bad enough) or bladder outlet obstruction

40
Q

Txt for post-renal failure: 2 parts

A

Identify/reverse the causes (get rid of obstruction), maintain fluid volume, and maintain electrolyte concentrations.

41
Q

what labs will you check for post-renal GFR? (4)

A

Check UA, GFR and serum BUN and creatinine.

42
Q

overview: txt of the 3 different kinds of ARF

A

Pre-renal: identify the cause and treat/reverse it, d/c nephrotoxic drugs, hydrate the patient

Intrinsic: identify the cause and treat/reverse it, d/c nephrotoxic drugs, possibly use dopamine, hydrate the patient, reperfusion of the kidney

Post-renal: identify/remove the obstruction

Dialysis or CRRT if needed for any type of ARF if it’s indicated

43
Q

CKD is defined by presence of kindey damage or loss of kindey function for …

A

three or more months

44
Q

CKD results in … and leads to ….

A

permanent loss of nephrons and frequently leads to renal failure.

45
Q

how is CKD classified? what is the staging based on?

A

Kidney Disease Outcome Quality Initiative (KDOQI)

GFR

46
Q

what are two of the most common causes for CKD?

A

DM and HTN

47
Q

what are the stages for CKD?

A

G5: GFR<15 (kindey failure)
count up in intervals of 15 … (G4, G3b, G3a, G2, G1)
G1: GFR >90 (kindey damage with normal or increased GFR)

48
Q

Stage 2 CKD is mildly reduced kidney function but also required

A

evidence of kidney disease (protienuria or hematuria)

49
Q

increased protien in urine indicates what? excretion of albumin leads to ____

A

increasing levels of protein in urine indicate kidney damage.
Excretion of albumin leads to CKD

50
Q

5 most common lab abnormalities in CKD

A 
GFR is decreased!
Proteinuria 
Broad waxy casts
anemia 
BUN (can go >800 )
51
Q

hyperkalemia in CKD: what stage does it occur and what is the txt?

A

is advanced- stage 5.

“C BIG K” (calcium, bicarbonate/beta-agonist, insulin + glucose, Kayexalate)

52
Q

metabolic acidosis in CKD?

A

Metabolic acidosis may occur when the pt is faced with a high acid load or loses alkali (like in diarrhea).

53
Q

anemia in CKD? what is the first line txt?

A

First line treatment: recombinant human erythropoietin (rhEPO),

54
Q

when should patients be monitored(have GFR checked) for the different stages of CKD?

A 
Consensus recommendations are: 
Stage 1 and 2	      annually
Stage 3A and B 	every 6 months
Stage 4 		every 3 months
Stage 5 		every 6 weeks
55
Q

Decrease in ________ that occurs in CKD results in less protein-bound drugs and greater amounts of free drugs.

A

plasma proteins (particularly albumin)- it is important in oncotic pressure for fluid shifts

56
Q

insulin with renal failure? what to do?

A

dose adjust!

57
Q

key to management of CKD: what stage does referral need to be made?

A

Timely Referral to a Nephrologist!!!!

At least by stage 3b CKD you need to be putting referrals into place!!!

58
Q

4 parts to general management of CKD

A
  1. treat UTIs appropriately
  2. Avoid smoking. (causes vasoconstriction that makes perfusion issues worse)
  3. Encourage weight loss.
  4. Evaluate for and treat reversible causes
59
Q

what are nephotoxic meds to avoid in CKD?

A

NSAIDs, COX 2 inhibitors, various abx (Macrobid, Bactrim).

60
Q

5 parts to treating complications of CKD?

A
  1. Volume overload
  2. Hyperkalemia
  3. HTN
  4. Acidosis
  5. Hyperphosphatemia/Hypocalcemia
61
Q

volume overload with CKD?

A

Early CKD: balance usually maintained
As CKD progresses, pt cannot respond to rapid changes in Na/H2O
Tx:
a. Na/H2O restriction
b. Loop diuretics (avoid thiazide diuretics)

62
Q

MAP for management of HTN and CKD (3 parts)

what is the MAP goal?

A
  1. Lower the MAP = slows progression (goal is <92 mmHg)
  2. Same in nondiabetics/diabetics
  3. Achieving BP goals is difficult

MAP Goal: 60-92 mmHg

63
Q

HTN with CKD: what is the overall HTN goal? BP goal?

A

HTN Goal: lower BP –> reduce proteinuria –> renoprotective and cardioprotective effects
BP GOAL: Systolic 110-129
Diastolic < 85

64
Q

what are the BP goals for proteinuric CKD pts?

A

In proteinuric patients: even lower BP goals
< 1 g/d: < 130/85
> 1 g/d: < 125/75

65
Q

4 parts of RAAS from glomerular HTN

A
  1. Glomerular HTN (occurs in efferent arteriole)
  2. Increases pro-inflammatory protein
  3. Stimulates aldosterone
  4. Proliferative effects of AT II –> tubular harm
66
Q

ACEs and ARBs: what do they do?

A

ACEIs – decrease production of angiotensin
ARBs – block receptor to accepting protein-direct Renin inhibitors, which reduces the effect of angiotensin on the blood flow and is renal protective

67
Q

management of CKD with HTN: 3 drug therapies

A
  1. ACEIs – drugs of choice HTN/proteinuria
  2. Diuretic – HCTZ-mild/moderate HTN (but to be avoided in late-stage CKD)
  3. Combination with ACEI or ARB – effective in nondiabetics/diabetics
68
Q

txt for acidosis in CKD?

A

Tx: Maintain HCO3 = > 22;
Give NaHCO3, 0.5 to 1 meq/kg/day; Na Citrate

DO NOT GIVE Al3+ containing antacids

69
Q

hyperphosphatemia and hypocalcemia: when does it start? what happens?

A

Starts early in renal disease
Drop in Calcium stimulates PTH –> decreased phosphorus resorption and increased calcium resorption from bone
= stimulates bone turn over and resorption

70
Q

3 goals of treatment for hyperphos and GFR <30: what levels do you want serum Calcium/phosphorus product, phosphorus, and serum total calcium?

A

(Ca x P) Product; <55

phosphorus: <5.0
calcium: 8.4-8.5

71
Q

hyperphosphatemia and GFR <30 requires txt, what will you do?

A

Treat with Phosphorus Binders:

  • Calcium Acetate
  • Calcium Carbonate
  • Non-Calcium Sevelamer (polymer)
72
Q

what is “AEIOU” for?

A

indications for dialysis

73
Q

what does AEIOU stand for?

A 
Acidosis
Electrolyte disturbance (severe hyperphosphatemia)
Ingestions (overdoses) 
Overload (pulmonary edema)
Uremia (uremic pericarditis)
74
Q

what are the risks of hemodialysis: what often results post-dialysis?

A

post-dialysis: hypotensive, low K+, nausea, etc.

75
Q

what is often the txt of choice for CKD patients?

A

transplant

76
Q

success of kidney transplant depends on what 3 things? what meds must patients take prior to transplant?

A

Success depends on histocompatibility, organ preservation, and immunologic management.
Pts will need immunosuppressive meds to control the T and B cell activation.

77
Q

what is continuous renal replacement therapy?

A

blood purification therapy intended to substitute for impaired renal function, normally the patient is hooked up for 24 hrs - good for unstable pts

78
Q

dietary management for CKD: what do you restrict and what do you want to make sure they are taking?

A

Restrict dietary proteins
ensure adequate caloric intake in the form of carbs and fats, sodium and fluid restrictions
-When GFR is very low or during hemodialysis, K+ restriction is recommended.
- Limit phosphorous

79
Q

renal dz of glomerular origin vs tubular dysfunction: how will each effect sodium in the body?

A

Renal dz of glomerular origin: Na retention

Tubular dysfunction: Na wasting

80
Q

water restriction of _____ -_____ for dialysis

A

500-800 mL

81
Q

CKD in children: can they get the same treatment as adults? what must you monitor?

A

if over 2 yo can get the same renal treatments as adults

-need to watch their BP

82
Q

what are age-adjusted measurements for GFR?

A

if youre older than 75, your GFR will NOT be 90, new normal for this age population.
60-89 GFR —> do age-adjusted meansurements

83
Q

uremic frost: what does it look like and what does it mean?

A

Bad sign- means they are uremic, especially if they have chest pain. looks like dandruff

NOTICE THIS

Pathophysiology (28 decks)

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