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Renal - Larmon > Renal Pathology, Diuretics, and Anesthesia > Flashcards

Renal Pathology, Diuretics, and Anesthesia Flashcards

1
Q

Two major pathways of natriuretic peptide

A
  1. vasodilator effects 2. renal effects that leads to natriuresis and diuresis
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2
Q

Natriuretic peptide is involved in the long-term regulation of _____ and _____ balance, blood volume and arterial pressure.

A

sodium and water

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3
Q

Natriuretic peptides directly dilate veins resulting in increased ______ ________ and thereby decrese _____, which reduces cardiac output by decreased _________ preload.

A

venous compliance / CVP / ventricular

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4
Q

Natriuretic peptides also dilate _______, which decreases ____ and systemic ________ pressure

A

arteries / SVR / arterial

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5
Q

NP affect the kidneys by ________ GFR and filtration fraction, which produces _________ (increased sodium excretion) and _________

A

increasing / natriuresis / diuresis

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6
Q

A second renal reaction of NPs is that they decrease _____ release, thereby decreasing circulating ________ and _______. This leads to further NATRIURESIS and DIURESIS. Decreased Angiotensin II also contributes to systemic _______ and decreased _____

A

renin / angiontensin II / Aldosterone / vasodilation / SVR

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7
Q

Natriuretic Peptides serve as a

A

counter-regulatory system for the renin-angiotensin-aldosterone system

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8
Q

ANP is produced by

A

atrial myocytes

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9
Q

ANP functions

A

relax smooth muscle AND promote NaCl and water EXCRETION by kdiney

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10
Q

Stimuli for ANP release

A

atrial stretch

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11
Q

Elevated levels of ANP are found during _________ states, such as occurs in heart failure

A

hypervolemic

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12
Q

ANP inhibits ______ release

A

renin

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13
Q

ANP increases GFR via vasodilation of the ________ arteriole and constriction of the _________ arteriole

A

afferent / efferent

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14
Q

ANP acts directly on the ______ ______ to decrease NaCl reabsorption

A

collecting duct

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15
Q

BNP is synthesized largely by the _____ as well as the brain where it was first identified

A

ventricles

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16
Q

BNP is first synthesized as prepro-BNP and then _______ twice to beecome BNP

A

cleaved

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17
Q

Natriuetic peptides are involved in the ____ term regulation of _____ and _____ balance, blood volume and arterial pressure

A

long / sodium and water

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18
Q

Cardiovascular an renal actions of NPs

A

natriuresis and diuresis, improve GFR and filtration fraction, inhibit renin release (decreases circulating Angiotensin II and Aldosterone), systemic vasodilation, arterial hypotension, redcued venous pressure, reduced PCWP

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19
Q

A substance that increases the rate of urine volume output

A

diuretic

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20
Q

Most clinically used diuretics act by decreasing the rate of ________ _________ from the tubules which causes sodium output to increase (natriuresis) which results in ________ (water output)

A

sodium reabsoprtion / diuresis

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21
Q

Common clinical use of diuretics is to decrease ___ volume and thus treat edema, CHF, or hyptertension

A

ECF

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22
Q

Although many diurectics work within minutes to effect decreases over the next few days with _____ use

A

chronic

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23
Q

What effects eventually override the effects of diuretics?

A

Decrease in ECF leads to decrease in MAP and decrease in GFR which eventually leads to Renin release

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24
Q

Review and draw slide 11

A

diuretics

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25
Q

Sometimes a combination of two diuretics is given because one nephron segment can ________ for altered sodium reabsorption at another nephron segment

A

compensage

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26
Q

Examples of osmotic diuretics

A

urea, mannitol

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27
Q

Osmotic diuretics, if injected into the bloodstream are filtered and FILTERED and not easily ________, thus they draw fluid into the ________

A

reabsorbed / tubules

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28
Q

Glucose can act as a _______ diuretic in diabetics who spill glucose in their urine resulting in increased urine output

A

osmotic

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29
Q

How do loop diuretics work?

A

they inhibit the Na-2Cl-K co-transporter in the TAL of Henle’s loop

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30
Q

With loop diuretics, there is inc reased delivery of solutes to the _______ tubule due to inhibited reabsoption, these solutes act as ______ agents to draw fluid into the tubule

A

distal / osmotic

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31
Q

With loop diuretics, this transporter normally reabsorbs 25% of the sodium load. However, the countercurrent multiplier system is disrupted and the interstitium cannot become ________

A

hyperosmolar

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32
Q

Loop diuretics also induce renal synthesis of _________, which contribute to their renal action including increase in renal blood flow and redistribution of renal cortical blood flow

A

prostaglandins

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33
Q

_________ are the most commonly used diuretics

A

thiazide

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34
Q

Thiazide diuretics work by inhibiting sodium chloride reabsorption in the ____ ______ _____

A

EARLY DISTAL TUBULE

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35
Q

Normally, the transported mechanism only absorbs ___% of filtered sodium in the distal tubule

A

5%

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36
Q

Are Thiazide diuretics more or less efficacious than loop diuretics in producing diuresis and natriuresis?

A

LESS

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37
Q

Loop and thiazide diuretics increase sodium delivery to the distal segment of the distal tubule, this increases potassium loss and potentially causes ________

A

hypokalemia

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38
Q

Carbonic Anyhydrase Inhibitors like _________ reduce reabsorption of Na+ in the ______ by decreasing _______ reabsorption

A

acetazolamide / PCT / bicarbonate

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39
Q

In the PCT, bicarbonate reabsorption is coupled to ______ reabsorption via Na+-H+ counter-transport

A

Na+

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40
Q

Aldosterone antagonists like _________ are also _______ sparing diuretics

A

Spironolactone / potassium

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41
Q

Aldosterone antagonists decreases reabsorption of ____ and decreases ___ secretion by competing for ______ binding sites in the distal segment of the DISTAL TUBULE

A

Na / K / Aldosterone

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42
Q

Aldosterone antagonists are often used in conjunction with ____ or ____ diuretics to help prevent HYPOKALEMIA

A

thiazide or loop

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43
Q

Na+ channel blockers like _____ and ______ decrease Na/K-ATPase in the ____ ______ and thereby decrease Na+ reabsorption. These diuretics also _____ potassium

A

amiloride / triamterene / collecting tubules / spare

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44
Q

Review slide 20

A

CLASS / MOA / Tubular site of Action

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45
Q

AKI

A

abrupt loss of kidney function within a few days, severe acute kidney injury where the kidneys may abruptly stop working entirely or almost entirely, patients with AKI may eventually RECOVER normal kidney function

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46
Q

CKD

A

An irreversible decrease in the number of functional nephrons

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47
Q

______ ______ is the leading cause of ESRD followed by _________

A

diabetes mellitus / HTN

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48
Q

Reflects an abnormality originating outside the kidney. Kidneys not getting enough blood flow and therefore becomes ischemic. Examples are heart failure and hypovolemia. What catefory of Acute renal failure is this?

A

Pre-renal AKI

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49
Q

Damage to the kidney itself. Examples include toxins, infections, autoimmune disease and direct renal injury. What category of Acute Renal Failure is this?

A

Infra-renal AKI

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50
Q

Obstruction of the collecting system anywhere from the calyces to the outflow of the bladder. Examples include stones, urethral valves, tied off ureter and kinked foley. What classification of Acute Renal Failure is this?

A

Postrenal AKI

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51
Q

With CKD, symptoms often do not occur until the number of functioning nephrons decreases to at ___% below normal

A

70%

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52
Q

CKD is usually defined as the presence of kidney damage or decreased kidney function that persists for at least ____ months

A

3 months

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53
Q

With CKD, relatively normal blood concentrations of most electrolytes and normal body fluid volumes can still be maintained until the number of functioning nephrons decreases below __ to ___% of normal

A

20 to 25

54
Q

______ is the term to describe a clinical syndrome characterized by renal dysfunction that would prove fatal without renal replacement therapy

A

ESRD

55
Q

ESRD GFR %

A

<25% of normal

56
Q

CRI GFR%

A

25-40% of normal GFR

57
Q

Decreased renal reserve GFR%

A

60-75% of normal GFR

58
Q

Patients with decreased renal reserve are often ______ and frequently do not have elevated blood levels of creatinine or urea.

A

asymptomatic

59
Q

Established renal insufficiency results in abnormal serum creatinine and BUN values but ________ may be the only symptom (due to reduced concentrating ability)

A

nocturia

60
Q

Injury to renal vasculature can be due to _________ of large vessels, _________ dysplasia, and __________ which refers to sclerotic lesions of smaller arteris, arterioles and golmeruli

A

atherosclerosis / fibromuscular / neprhosclerosis

61
Q

Glomerulonephritis is most commonly caused by deposition of _____-______ complexes in glomerular membranes

A

antigen-antibody

62
Q

Glomerulonephritis can be post _________ infection and ________ can cause this as well

A

streptococcal / lupus

63
Q

Atherosclerotic or hyperplastic lesions of the large arteries frequently affect one kidney more than the other and, therefore cause _________ diminshed kidney function

A

unilaterally

64
Q

Benign _________ is th most common form of kidney disease. When sclerosis occurs in the glomeruli, the injury is referred to as ________

A

nephrosclerosis / glomerulosclerosis

65
Q

_________ __________ is when the bladder wall fails to coolude the ureter during micturation and contaminated urine from the lower urinary tract is propelled retrograde into the kidney and can result in an INFECTION

A

Vesicoureteral reflux

66
Q

_____ _______ is a condition where large amounts of protein are lost in the urine due to destruction of or loss of negative charge on the capillary basement membrane in the glomerulus

A

nephrotic syndrome

67
Q

Pyleoneprhritis review

A

most common organism is E.coli, begins in renal medulla and affects it more than cortex, since countercurrent mechanism is in medulla they often have difficulty concentrating urine

68
Q

______ is the effect of renal failure on the body

A

uremia

69
Q

______ ____ is a constellation of signs and symptoms of anorexia, N/V, pruritis, anemia, fatigue, coagulopathy that reflects the kidney’s progressibe inability to perform its excretory, secretory and regulatory functions

A

uremic syndrome

70
Q

The most important RISK FACTOR for ESRD is _________ being that it is a major cause of both diabetes and hypertension

A

obesity

71
Q

Renal failure and ESRD

A

prone to pulmonary edema and fluid overload, minute ventilation is increased to compensate for acidosis, osteomalacia

72
Q

Osteomalacia

A

Vit D is convereted in two steps (1st in liver and then in kidneys) before it can promote Ca++ absoroption from the intestine. Thus decreases in the active form of virtamin D are seen. Also the rise in phosphate concentration stimulates PTH which causes skeletal muscle demineralization (secondary hyperparathyroidism)

73
Q

More effects of renal failure (review)

A

abnormal glucose tolerance, platelet and WBC dysfunction, hypersecretion of gastric acid increases risk of ulcers, autonomic neuropathy can slow gastric emptying, peripheral neuropathy is common

74
Q

Kidney lesions which decrease ____ and ______ excretion promote _______

A

sodium / water / hypertension

75
Q

If one kidney or part of one is ischemic or damaged the normal kidney gets _________ because renin and angiontensin II from the ischemic kidney affect the normal kidney and drives up BP

A

punished

76
Q

The ischemic renal tissue secretes large quantities of ____

A

renin

77
Q

Effective treatment of hypertension related to kidney disease requires enhancing the kidney’s capability to excrete ______ and ______. This is accomplished by increasing _____ or by decreasing _____ ______.

A

salt and water / GFR / tubular reabsorption

78
Q

With dialysis, the artifical kidney passes blood across a thin membrane, on the other side of the membrane is a dialyzing fluid where undesired substances pass by ________

A

diffusion

79
Q

With dialysis, the rate of movement of solute across the membrane depends oon the _____ _____ of the solute and the permeability and surface area of the membrane and also the length of time the blood and fluid remain in contact with the membrane

A

concentration gradient

80
Q

With dialysis, the maximum rate of solute transfer occurs initially when the concentration gradient is _________ (when dialysis begins)

A

greatest

81
Q

How much blood is usually in the dialysis machine at any time?

A

500 cc

82
Q

Is there phosphate, urea, urate, sulfate or creatinine in the dialyzing fluid?

A

NO

83
Q

Indications for dialysis

A

fluid overload, hyperakalemia, severe acidosis, metabolic encephalopathy, pericarditis, coagulopathy, refractory GI symptoms, drug toxicity

84
Q

BUN normal is

A

10-20 mg/dL

85
Q

Ammonia is converted to urea in the ____ and urea is handled by the ______

A

liver / kidney

86
Q

___ to ___% of urea is passively reabsorbed in the nephron, _________ wiill increase this

A

40-50% / hypovolemia

87
Q

Increased BUN can be from decreased ______ or increased _______ breakdown

A

GFR / protein

88
Q

Patients on hemodialysis should undergo dialysis during the ____ hrs preceding elective surgery

A

24 hrs

89
Q

normal creatinine in men

A

0.8 to 1.3

90
Q

Normal creatinine in women

A

0.6-1

91
Q

Creatinine concentration is directly related to _____ _____ mass and inversely related to _____

A

body muscle / GFR

92
Q

_______ ________ is a way to measure GFR

A

creatinine clearance

93
Q

GFR _______ with age in most people.

A

decreases (5% decline per decade after age 20)

94
Q

Creatinine clearance formula

A

140-Age x IBW / 72 x creatinine **multiply CC by 0.85 for women

95
Q

BUN / creatinine rationis > 10:1 are seen in ____ _______ or conditions associated with decreased tubular flow and obstructive uropathy

A

volume contraction

96
Q

urinary pH is helpful when arterial pH is known. Urinary pH > 7.0 in the presence of systemic acidosis is suggestive of renal _____ _____

A

tubular necrosis

97
Q

Specific gravity is related to _______ osmolality

A

urinary

98
Q

A low specific gravity in the face of plasma hyperosmolality is consistent with _____ _____

A

diabetes insipidus

99
Q

Patients with renal disease are more susceptible barbiturates because or decreased ____ ______

A

protein binding

100
Q

Propofol, ketamine and etomidate have no significant differences in _____ patients

A

uremic

101
Q

Extra caution with ______ since active metabolites can accumulate

A

diazepam

102
Q

Dexmedetomidine is primarily metabolized in the ______. Renal impairment may cause longer lasting effects related to less ______ ______

A

liver / protein binding

103
Q

T/ F Significant renal impairment may affect the disposition, metabolism, and excretion of the commonly used anesthetic agents

A

TRUE

104
Q

Opiod cautions with renal failure

A

morphine, demerol and hydromorphone BAD. Use fentanyl

105
Q

Succinylcholine is safe in patients with K <5.0 but will transiently increase K+ by almost ___mEq/L

A

0.5

106
Q

Drug of choice is ______ for renal failure

A

cisatracurium

107
Q

_____ ______ are the most likely foup of drugs used in anesthetic practice to produce prolonged effects in ESRD because of their dependence on renal excretion

A

muscle relaxants

108
Q

Muscle relaxants to avoid that depend primarily on renal excretion

A

pancuronium, pipecuronium, alcuronium, doxacurium

109
Q

With ESRD, elective surgery should be below ____mEq/L. If it is not, we generally dialyze the patient for a minumum of ___ hrs

A

5.5 / 2

110
Q

T/F peritoneal dialysis is generrally performed until just prior to the procedure and the dialysate should be drained prior to the procedure

A

TRUE

111
Q

What fluids do you want to avoid with ESRD and why?

A

LR because of the potassium

112
Q

_____ ______ may be the best as it will decrease the risk of respiratory acidosis which is not good in the setting of metabolic acidosis

A

controlled ventilation

113
Q

Algorithm on slide 55

A

anesthesia for the dialysis patient

114
Q

For patients with mild to moderate renal impairment, _______ is a key facator in the causation of periop renal failure.

A

hypovolemia

115
Q

post-op renal failure has a mortality of ____%

A

50%

116
Q

Prophylaxis for patients with mild to moderate renal failure may be

A

mannitol 0.5g/kg

117
Q

Risk factors for perioperative renal failure

A

sepsis, hypovolemia, obstructive jaundice, aminoglycoside antibiotics, NSAIDS, ACE inhibitors, recent dye injections

118
Q

Rational management of intraoperative oliguria

A

First make sure foley is patent, assess fluid status, admin bolus if needed and observe, check CVP, increase BP if it is low, if patient is on lasix they may need their daily dose, consider mannitol

119
Q

Most common composition of renal stones

A

calcium oxalate

120
Q

Who is more likely to get a kidney stone

A

men

121
Q

Most stones <4mm pass _______

A

spontaneously

122
Q

Alpha blockers like _____ may help decrease tone of ureter and promote passage of stone

A

terazosin

123
Q

May have surgical mangement of larger stone or if stone has not passed in ___ days

A

30

124
Q

ESWL is used for disintegration of stones in the kidney or ureter above the level of the ____ ____

A

iliac crest

125
Q

Contraindiciations to ESWL

A

inability to properly position patient, pregnancy, infection, obstruction below the level of the stone, proximity of prosthetic device

126
Q

With ESWL shocks are timed for 20 ms after the ___ wave so it is deliverd during the ventricular _____ _____

A

R / ventriular refractory

127
Q

Stone prevention

A

drink water, avoid cola beverages, limit protein, nitrogen and sodium in diet

128
Q

With Gout, 75% of first attacks involve the ___ ____. Serum urate is not always ________.

A

big toe / urate

129
Q

Gout is more common where there is a diet rich in _____, _____ and _____

A

protein / fat / alcohol

130
Q

GOUT pain relief involves NSAIDs (first line) and _________ which works by alkalinizing the urine which traps weak acids

A

acetazolamide

131
Q

Gout prevention

A

allopurinol (watch out fatal interacction with azathioprine which is a transplant drug can be fatal), uricocurics, caffeine, CPAP

Renal - Larmon (3 decks)

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