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AS - N935 Advanced Patho II > Renal Pathophysiology > Flashcards

Renal Pathophysiology Flashcards

1
Q

Kidneys receive ___% total CO

A

15-25%

95% directed to the renal cortex (glomerulus)
5% to the medulla

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2
Q

Renal Autoregulation

A

INTRINSIC - intact even in denervated kidneys

Tubuloglomerular feedback

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3
Q

Renal Blood Flow

A

Afferent arteriole → glomerular capillary → Bowman’s capsule → proximal tubule → loop of Henle descending → ascending → macula densa → distal tube collecting duct

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4
Q

Glomerulus

A

Separates the afferent from efferent arterioles
Resistance in efferent arterioles creates hydrostatic pressure w/in glomerulus
Capillaries lined w/ podocytes

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5
Q

GFR

A

Glomerular filtration rate
Rate blood filtered through all glomeruli
Measures overall kidney function

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6
Q

SNS Activation

A

↓RBF
Blood shunted to skeletal muscle during exercise
Surgical stimulation ↑vascular resistance
Stimulates adrenal medulla → catecholamine release
↓BP → RAAS activation

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7
Q

ADH

Vasopressin

A 
Antidiuretic hormone
Released in response to ↓stretch receptors in atrial/arterial wall & ↑plasma osmolality
Synthesized in hypothalamus
Released from posterior pituitary
Half-life 16-24 minutes
Constrict efferent arteriole
H2O reabsorption
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8
Q

ADH Primary Functions

A
  1. ↑renal H2O reabsorption (osmolality)

2. Vasoconstriction ↑SVR ↑BP

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9
Q

Periop Release ADH Causes

A 
Hemorrhage
PPV +
Upright position
Nausea
Medications
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10
Q

Renin

A 
Enzyme secreted by kidneys
Hydrolyzes angiotensin → angiotensin I
Released from JG cells near afferent arterioles
- ↓arterial BP
- ↓Na+ load delivered to distal tubules
- SNS β1 receptors
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11
Q

Angiotensin

A

Angiotensin I converted in the lungs by ACE into angiotensin II
Angiotensin II potent vasoconstrictor & stimulates hypothalamus to secrete ADH

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12
Q

Aldosterone

A

Mineralocorticoid hormone released from the adrenal gland
Plasma half-life 20 minutes
Stimulates epithelial cells in distal tubule & collecting ducts to reabsorb Na+ & H2O (exchanges K+ to maintain electroneutrality)

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13
Q

Spironolactone

A

K+ sparing diuretic that blocks the aldosterone receptors

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14
Q

Acute Renal Failure

AKI

A

Sudden inability to produce urine
Develops rapidly but may resolve
50% mortality rate

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15
Q

Pre-Renal

A

Hemodynamic or endocrine factors impair perfusion
Causes - hypotension, shock, hypovolemia, hemorrhage, burns (fluid shift), vascular occlusion (thrombosis or clamping), ↓RBF (heart failure or renal artery stenosis), hepato-renal syndrome
Activate RAAS → ADH
Low urine Na+ ↑osmolality
Possible to progress to permanent parenchymal damage

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16
Q

Intra-Renal

Acute Tubular Necrosis

A

Direct kidney tissue damage
Causes - inflammation/infection, reduced blood supply, prolonged ischemia, nephrotic injury (antibiotics, chemo, contrast dye), glomerulonephritis
Parenchymal disease difficult to concentrate urine
↑urine Na+ ↓osmolality

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17
Q

Post-Renal

A

Urinary outflow obstruction
Causes - kidney stones (calculi), stricture, blood clots, neoplasm, bladder/pelvic tumor, prostate enlargement, or injury
Less common in OR setting

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18
Q

Anuria

A

<100mL/day

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19
Q

Oliguria

A

<400mL/day
<0.5mL/kg/hr

OR oliguria indicates inadequate systemic perfusion

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20
Q

Polyuria

A

> 2.5L/day

Non-concentrated urine

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21
Q

Acute Renal Failure

AKI Risk Factors

A

↓renal reserve w/ age
Each year after 50 creatinine clearance ↓1.5mL & renal plasma flow ↓8mL
Pre-existing renal dysfunction
Surgical procedures
- Cardiac bypass >2 hours
- Aortic aneurysms (supra-renal aortic clamping)
- Ventricular dysfunctions
Sepsis - hypovolemia, hemolysis, DIC, infections, acidosis
Nephrotoxic agents
Diabetes
Hypertension

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22
Q

AKI Prevention

A

Prevention renal insult more successful than management
Hydration
Maintain blood pressure
Euvolemia

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23
Q

Contrast-Induced Nephropathy

A

3rd most common cause hospital acquired AKI
Results from iodinated contrast media admin
Transient & reversible acute renal failure
1° supportive treatment
- Fluid & electrolyte management
- Dialysis
Low incidence in normal renal function patients 0-5%
Pre-existing renal impairment 12-27%
Diabetic neuropathy up to 50%

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24
Q

CIN Risk Factors

A 
Pre-existing renal disease
Diabetes
Hypertension
Volume-status (dehydration)
Obesity
Hepato-renal injury
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25
Q

CIN Pathology

A

Unclear
Hypoxia & hypo-perfusion exacerbate injury
Direct contrast media toxicity r/t harmful effects free radicals & oxidative stress
Excreted contrast in renal tubules generates osmotic force causing ↑Na+/H2O excretion
Diuresis ↑intratubular pressure ↓GFR → acute renal failure

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26
Q

CIN Treatment

A

Supportive
Prevention = key
Contrast media diagnostic studies or interventional procedures weigh risk against benefit

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27
Q

Intraop Monitors

A 
Rapid recognition & treatment to prevent renal insult
Foley
Transesophageal echocardiogram
CVP (less accurate)
Blood pressure
Stroke volume variation
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28
Q

Oliguria Treatment

A

Assume pre-renal oliguria r/t fluid until proven otherwise
Blood
Selective dopamine receptor agonists cause renal arteriolar vasodilation - Fenoldopam & low-dose dopamine <3mcg/kg
Diuretics - Furosemide or Mannitol (do not admin in patient w/ intravascular hypovolemia)

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29
Q

Chronic Renal Failure

A

Slow, progressive, & irreversible
↓nephron function ↓RBF ↓GFR
Causes - glomerulonephritis, pyelonephritis, diabetes, vascular or hypertensive insults, or congenital defects

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30
Q

Renal Insufficiency

A

↓renal reserve asymptomatic until <40% normal nephron remain
Insufficiency when 10-40% functioning nephrons remain
Compensated w/ minimal renal reserve

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31
Q

ESRD

A

End-stage renal disease/failure
>95% nephrons non-functioning
GFR <5-10% normal
Severely compromised electrolyte, hematologic, & acid-base balance
Uremia - urine in the blood eventually lethal
Dialysis dependent

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32
Q

Chronic Renal Failure S/S

A 
Hypervolemia
Acidemia
Hyperkalemia
Cardiorespiratory dysfunction
Anemia
Bleeding disturbances
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33
Q

Chronic Renal Failure Treatment

A

Hemodialysis HD
Peritoneal dialysis PD
Kidney transplant

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34
Q

Urine Specific Gravity

A

Measure solutes present in urine
Indicates kidneys ability to excrete concentrated urine
Reflects tubular function

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35
Q

Urine Osmolality

A

Number moles solute per kilogram solvent
More specific than specific gravity
Ability to excrete concentrated urine indicates adequate tubular function

36
Q

Proteinuria

A

> 150mg excreted per day
750mg (3+ or 4+) indicates severe glomerular damage
Failure renal tubules to reabsorb protein

37
Q

Urinary pH

A

Inability to excrete an acid urine in presence acidosis

Indicates renal insufficiency

38
Q

Glucose

A

Freely filtered at glomerulus
Reabsorbed in proximal tubule
Glycosuria indicates renal tubules ability to reabsorb glucose exceeded by abnormally heavy glucose load
Indicates diabetes mellitus

39
Q

BUN

A

Blood urea nitrogen
Not direct renal function
Influenced by exercise, bleeding, steroids, & tissue breakdown
Elevated in kidney disease when GFR reduced to 75%

40
Q

Serum Creatinine

A

Muscle tissue turnover & dietary protein intake
Creatinine freely filtered at glomerulus & neither reabsorbed nor secreted
Creatinine clearance measures GFR

41
Q

↑Creatinine

A

Ketoacidosis
Cephalothin/Cefoxitin
Flucytosin
Other drugs - ASA, cimetidine, probenecid, trimethoprim (inhibit tubular creatinine secretion)

42
Q

↓Creatinine

A

Advanced age (elderly) physiologic ↓muscle mass
Cachexia pathologic ↓muscle mass
Liver disease ↓hepatic creatinine synthesis

43
Q

GFR

A

Glomerular filtration rate
Best measure glomerular function
Normal 125mL/min
ASYMPTOMATIC until GFR decreases to <30-50% normal

44
Q

Hyperkalemia

A

Peaked T waves

Small or indiscernible P waves

45
Q

PRBCs

A

Blood storage → constant potassium leak
Potassium ↑0.5-1mmol/L per day refrigerator storage
Blood stored in blood bank up to 42 days

46
Q

Minimize Transfusion Hyperkalemia Risk

A

Select blood collected <5 days prior to transfusion
Wash blood immediately before infusion to remove extracellular potassium
K+ absorption filters during transfusion to decrease K+ loading
Rate & volume contribute to K+ levels as well as patient pre-transfusion circulating blood volume

47
Q

General Anesthesia

A

PPV ↓CO

↓RBF, GFR, urinary flow, & electrolyte secretion

48
Q

Regional Anesthesia

A

Parallels w/ SNS blockade degree

↓VR ↓BP

49
Q

Direct & Indirect Effects

A 
Direct:
- Medications that target renal cellular function
Indirect:
- Circulatory
- Endocrine
- SNS
- Patient positioning
50
Q

Surgery Impact on Renal Disease

A

Stress & catecholamine release
Fluid shifts
Vasopressin & angiotensin secretion

51
Q

Opioids

A

Morphine - active metabolites depend on renal clearance
Meperidine - normeperidine active metabolite
Fentanyl ↓plasma protein binding ↑free fraction available

CKD ↓opioid dosages

52
Q

Ketamine

A

Hepatic metabolism
Norketamine metabolite hydroxylated into water-soluble
Renal excretion

53
Q

Gabapentinoids

A

Gabapentin (Neurontin) & Pregabalin (Lyrica)
Solely renal excretion
↓dose 50% each 50% ↓GFR
↑time interval b/w doses

54
Q

Inhalational Agents

A

Hypotension → compensatory ↑renal vascular resistance ↓RBF
Isoflurane ↓BP (dose-dependent)
Desflurane ↓BP ↑HR maintain CO & renal perfusion
Sevoflurane - free fluoride ion metabolite

55
Q

Compound A

A

CO2 absorbents containing soda lime (KOH, NaOH, H2O, CA(OH)2) degrade Sevoflurane resulting in production vinyl ether
Higher risk w/ closed-circuit anesthesia
Dependent on duration exposure, FGF, & concentration

56
Q

Propofol

A

Does not adversely affect renal tubular function
Prolonged infusion → green urine d/t presence phenolic metabolites
Discoloration does not affect renal function
PRIS - renal failure 2° rhabdomyolysis, myoglobinuria, hypotension, metabolic acidosis

57
Q

Succinylcholine

A

Careful admin
Rapid transient ↑K+0.5mEq/L
Metabolism pseudocholinesterase → succinic acid & choline
Metabolic precursor succinylmonocholine renal excretion
Preop & postop dialysis w/in 24 hours

58
Q

NDMRs

A

Prolonged elimination 1/2 life
Vecuronium 0.9 → 1.4hr 30% renal excretion
Atracurium 0.3 → 0.4hr (Hoffman elimination)
Pancuronium 1.7 → 8.2hr
Rocuronium 0.7 → 1hr
Mivacurium 0.03 → 0.06hr

59
Q

Sugammadex

A

Cyclodextrin molecules inactivate aminosteroidal NMBs
Renal excretion
Cyclodextrin complexes accumulate in severe renal impairment
Insufficient data concerning long-term exposure

60
Q

Sodium Nitroprusside

A

Nitroprusside → cyanide → thiocyanate

Thiocyanate 1/2 life >4 days (prolonged in renal failure)

61
Q

Thiocyanate Toxicity

A

Levels >10mg/100mL
Associated w/ long-term infusions >6 days
Hypoxia, nausea, tinnitus, muscle spasm, disorientation, & psychosis

62
Q

Albumin

A

Protective

Maintains renal perfusion, binds endogenous toxins, nephrotoxic drugs, & prevents oxidative damage

63
Q

Hetastarch/Dextran

A

Associated w/ AKI 2° breakdown synthetic carbohydrates to degradation products that cause direct tubular injury & tubules plugging
Worsened w/ ↓renal perfusion

64
Q

Dopaminergics

A

Fenoldopam selective D1 agonist
Low-dose dopamine
Dilate afferent & efferent arterioles
↑renal perfusion

65
Q

Anti-Dopaminergics

A

Metoclopramide, Droperidol, & phenothiazines

Impair renal response to dopamine

66
Q

Renal Cell Carcinoma

A 
Most common renal malignancy
80% all solid renal masses
Originates in proximal tubules lining
Refractory to chemotherapy or radiation
Classic triad presentation
Surgical resection often curative
67
Q

Classic Triad Presentation

A

Hematuria
Flank pain
Renal mass

68
Q

Renal Dysplasia

A

Renal tubules malformation during fetal development
Irregular cysts
Utero diagnosis via ultrasound
Bilateral incompatible w/ survival
90% patients have contralateral hypertrophy as adults (healthy kidney compensation)
→ CKD, dialysis, transplant

69
Q

Polycystic Kidney Disease

A

Inherited (dominant or recessive) renal enlargement w/ compromised function
Non-functioning fluid filled cysts microscopic to mass-effect size
Cysts present on other organs (liver, pancreas, spleen)
Painful d/t cyst distension & fascia stretching
- Hemorrhage, rupture, or infection exacerbate pain

70
Q

PKD Complications

A

HTN d/t RAAS activation
Cyst infections
Bleeding
Decline in renal function

71
Q

PKD Treatment

A

Symptom management
Dialysis
Transplant

72
Q

Wilm’s Tumor

A

Nephroblastoma
Unilateral painless, palpable abdominal mass
Associated w/ congenital/genetic malformations
Most common pediatric malignant renal tumor
1/3 occur under 1yo
Resection & possible chemo
RAPID growth
Metastasis → lungs

73
Q

Wilm’s Tumor

Stage 1

A

43%
Limited to kidney
Completely excised

74
Q

Wilm’s Tumor

Stage 2

A

23%

Tumor extends beyond kidney but completely excised

75
Q

Wilm’s Tumor

Stage 3

A

20%

Inoperable primary tumor or lymph node metastasis

76
Q

Wilm’s Tumor

Stage 4

A

Lymph node metastases outside abdominopelvic region

77
Q

Wilm’s Tumor

Stage 5

A

Bilateral renal involvement

78
Q

Total Nephrectomy

A

Renal artery & vein ligated
Remove kidney, ipsilateral adrenal gland, perinephric fat, & surrounding fascia
Other kidney needs to be functional

79
Q

Partial Nephrectomy

A

Nephron sparing surgery
Patients w/ solitary functional kidney, small lesions <4cm, or bilateral tumors
↑risk patients d/t other comorbidities diabetes or HTN
Open, laparoscopic, and/or robotic

80
Q

Nephrectomy

Anesthetic Considerations

A 
Type + cross
CBC & electrolytes
Regional anesthesia nerve roots T8-L3
ERAS
Opioid sparing
81
Q

Parathyroid Hormone

A

↑Ca2+ reabsorption

Exchange phosphate

82
Q

Erythropoietin

A

Released from kidney in response to anemia or hypoxemia

83
Q

ANP

A

Atrial natriuretic peptide
Fluid overload → atrial distension
Stimulates Na+ & H2O excretion

84
Q

Dopamine

A

DA1 receptor
Located in renal vasculature
Vasodilation & Na+ excretion

85
Q

Nephrons

A

Each kidney has 1 million nephrons

2 kidney nephrons end-to-end 10 miles

86
Q

Kidneys filter blood _____ times per day

A

20-25x per day

87
Q

Renal Agenesis

A

Born w/ one kidney or kidney removed

Body only loses 25% kidney function d/t hypertrophy to sustain the body

AS - N935 Advanced Patho II (20 decks)

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