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NRP511 > Renal pathophysiology part II > Flashcards

Renal pathophysiology part II Flashcards

1
Q

Glucose is freely filtered at

A

the glomerulus

reabsorbed in the proximal tubule

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2
Q

Glycosuria signifies that the ability of the renal tubules to

A

reabsorb glucose has been exceeded by an abnormally heavy glucose load & is usually indicative of diabetes mellitus

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3
Q

Conditions that cause elevated serum creatinine include

A

ketoacidosis
cefoxitin
flucytosine
other drugs- aspirin, cimetidine, probenecid, trimethoprim

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4
Q

Conditions that cause decreased creatinine include

A

advanced age
cachexia
liver disease

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5
Q

A good measure of GFR is

A

creatinine clearance

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6
Q

The best measure of glomerular function is

A

glomerular filtration rate

  • normal is 125 mL/min
  • people are asymptomatic until GFR decreases to <30-50% of normal
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7
Q

Blood urea nitrogen is not

A

a direct renal function
it is influenced by exercise, bleeding, steroids, & tissue breakdown
-is elevated in kidney disease once GFR is reduced to ~75%

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8
Q

Serum creatinine is due to

A

muscle tissue turnover and dietary intake of protein

****creatinine is freely filtered at the glomerulus and is neither reabsorbed nor secreted

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9
Q

The best mechanism that we have to assess kidney function is

A

serum creatinine

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10
Q

Describe ECG in patients with renal disease.

A

ECG reflects the toxic effects of potassium excess more closely than determination of the serum potassium concentration
will see peaked T waves*
Small or indiscernible P waves

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11
Q

Clinical situations that contribute to increased K+ in renal failure patients include

A 
protein catabolism
hemolysis
hemorrhage
tx. of stored RBCs
metabolic acidosis
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12
Q

How long are RBCs stored in blood bank?

A

42 days

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13
Q

During blood storage, there is a slow but constant leakage of

A

potassium from the cells that results in a plasma level of potassium increase by 0.5-1.0 mmol/L/ per day of refrigerator storage

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14
Q

The risk of potassium overload in patients requiring a blood transfusion can be minimized by

A

selecting only blood collected less than 5 days ** prior to transfusion and by washing *** any unit of blood immediately before infusion to remove extracellular potassium

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15
Q

The use of potassium absorption ______ during transfusion may also decrease potassium loading

A

filters****

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16
Q

Factors that also play a role in the increase of potassium levels with transfusion are

A

the rate and volume***** of transfusion as well as the patient’s circulating pre-transfusion blood volume

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17
Q

Imaging studies in renal disease include

A

ultrasound, CT, & MRI

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18
Q

Ultrasound in renal disease provides

A

noninvasive, minimal patient prep, assesses kidney size, hyponephrosis, vasculature, obstructions, & masses

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19
Q

CT in renal disease is used to

A

detect stones of all kinds, masses may be evaluated using contrast

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20
Q

MRI in renal disease is used to

A

provide detailed tissue characterization, nice alternative to a contrast CT, reduced radiation exposure (e.g. pregnant)
Gandolinium is a paramagnetic IV contrast agent used commonly in MRA

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21
Q

Describe how general anesthesia effects renal function

A

PPV & decreased CO–> depression of renal blood flow, GFR, urinary flow, & electrolyte secretion

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22
Q

Describe how regional anesthesia effects renal function

A

parallels with degree of SNS blockade, decreased venous return, & decrease in blood pressure

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23
Q

Indirect effects perioperative effects on renal function include

A

circulatory, endocrine, SNS, patient positioning

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24
Q

Describe the direct effect perioperative effects on renal function.

A

medications that target renal cellular function

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25
Q

Describe how surgery effects renal function.

A

causes stress & catecholamine release, fluid shifts, secretion of vasopressin & angiotensin

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26
Q

Describe how fentanyl is affected by renal failure.

A

not grossly altered by renal failure but a decrease in plasma protein binding may result in higher free fractions

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27
Q

Describe how meperidine is affected by renal failure

A

active metabolite normeperidine is dependent on renal excretion- accumulation can lead to CNS toxicity & seizures

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28
Q

Describe how morphine is affected by renal failure

A

active metabolites that depend on renal clearance mechanisms for elimination
-morphine-6-glucuronide**** is excreted via the kidney

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29
Q

Describe the use of morphine & hydromorphone for patients at risk or early stage of CKD, advanced CKD, & ESRD/hemodialysis.

A

Morphine- early stage reduce dose, advanced CKD & ESRD avoid completely
hydromorphone- early stage 1-2 mg q4 h, advanced CKD decrease to 1 mg, ESRD decrease to 0.5 mg

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30
Q

Describe CKD & ketamine

A

8% of administered ketamine is metabolized in the liver forming norketamine; norketamine is then hydroxylated into a water-soluble metabolite excreted by the kidney
most clinicians believe that dose modification for ketamine is not required for patients with decreased renal function

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31
Q

Describe the use of gabapentinoids (gabapentin & pregabalin) for patients with renal failure.

A

may increase the risk of over sedation & even coma
these agents are excreted solely by the kidney**
a reduction of 50% of the dose for each 50% decline in GFR or CCr** and increasing the time interval between the doses is advised

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32
Q

Describe the use of isoflurane on renal function

A

decreases BP (dose dependent)

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33
Q

Describe the use of desflurane on renal function.

A

with increased heart rate, may maintain a greater degree of CO and therefore renal perfusion

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34
Q

Describe the use of sevoflurane on renal function.

A

free fluoride ion metabolite

-was more pronounced & only proven with methoxyflurane & clear evidence has not been established with sevoflurane

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35
Q

What other metabolite is associated with sevoflurane?

A

Compound A

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36
Q

Risk of development of compound A is dependent on

A

duration of exposure, fresh gas flow rate, concentration of sevoflurane

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37
Q

Co2 absorbents containing _________ degrade sevoflurane resulting in production of

A

soda lime; vinyl ether called compound A

risk is higher with closed-circuit anesthesia

38
Q

The sevoflurane FDA package insert states

A

sevoflurane exposure should not exceed 2 MAC hours at flow rates of 1 to <2 L/min.
FGF <1L/min. are not recommended

39
Q

____ can be used in place of soda lime

A

Amsorb
non-caustic and can be disposed of in domestic waste
no production of compound A even when desiccated and low flows with sevo are safe

40
Q

Propofol does not

A

adversely affect renal tubular function

41
Q

Prolonged infusions of propofol may result in

A

green urine due to the presence of phenolic metabolites

-this discoloration does not affect renal function

42
Q

Propofol infusion syndrome can result in

A

renal failure secondary to rhabdomyolysis, myoglobinuria, hypotension, & metabolic acidosis

43
Q

The duration of action of muscle relaxants in patients with renal failure

A

may be prolonged***

44
Q

Succinylcholine & patients with renal failure

A

can be used carefully

okay if patient has received dialysis within 24 hours & normal serum K+

45
Q

Administration of succinylcholine causes a

A

rapid, transient increase of 0.5 mEq/L in the serum potassium concentration
- can be exaggerated to >0.5 mEq/L in the patient with renal failure

46
Q

Succinylcholine’s metabolism is catalyzed by

A

pseudocholinesterase to yield the nontoxic end products succinic acid & choline
- the metabolic precursor of these two compounds, succinylmonocholine, is excreted by the kidneys

47
Q

With sugammadex, the neuromuscular blocker complex is

A

excreted by the kidney**

in patients with severe renal impairment, these cylcodextrin complexes can accumulate

48
Q

______ is an intermediate in the metabolism of sodium nitroprusside

A

cyanide; with thiocyanate being the final metabolic product

49
Q

The half-life of thiocyanate is normally

A

more than 4 days and it is prolonged in patients with renal failure

50
Q

When thiocyanate levels are more than 10 mg/100 mL

A

hypoxia, nausea, tinnitus, muscle spasm, disorientation & psychosis have been reported

51
Q

Thiocyanate toxicity is associated with

A

long-term infusions (usually more than 6 days)

52
Q

Describe what fluids should be considered for patients with renal failure.

A

albumin- may be protective by maintaining renal perfusion, binding of endogenous toxins & nephrotoxic drugs, & preventing oxidative damage
Hetastarch/Dextran- has been associated with AKI secondary to the breakdown of the synthetic carbs to degradation products that cause direct tubular injury & plugging of tubules

53
Q

Dopamine & fenoldopam have been used to

A

dilate afferent and efferent arterioles and increase renal perfusion

54
Q

Anti-dopaminergics & renal failure

A

may impair renal response to dopamine

(metoclopramide, phenothiazines, droperiodol

55
Q

Renal pathophysiologies requiring surgeries include

A

renal cell carcinoma
renal dysplasia
polycystic kidney disease
& Wilm’s Tumor

56
Q

The most common renal malignancy is

A

renal cell carcinoma

>80% of all solid renal masses

57
Q

Renal cell carcinoma originates

A

in the lining of the proximal tubules

58
Q

Renal cell carcinoma is refractory to

A

chemotherapy or radiation

59
Q

The classic triad presentation of renal cell carcinoma is

A

hematuria, flank pain, & renal mass****

although often found incidentally ~50%

60
Q

__________ is often curative for renal cell carcinoma

A

surgical resection

61
Q

For 5-10% of patients with renal cell carcinoma, the tumor extends into

A

the renal vein & the inferior vena cava & right atrium

-may require CPB

62
Q

Renal dysplasia is the

A

malformation of the tubules during fetal development

kidney consists of irregular cysts of varying sizes

63
Q

The diagnosis of renal dysplasia is often made

A

in utero by ultrasound

64
Q

Renal dysplasia is linked to

A

genetic mutation & illicit drug use by mother (e.g. cocaine)

65
Q

Patients with renal dysplasia may also have

A

ureteropelvic junction obstruction & vesicoureteral reflux

66
Q

______ is incompatible with survival for patients with renal dysplasia

A

bilateral

67
Q

Renal dysplasia can lead to

A

chronic kidney disease, dialysis, & transplant

68
Q

About 90% of patients with renal dysplasia will have

A

contralateral hypertrophy by adulthood

69
Q

Polycystic kidney disease is

A 
an inherited (dominant or recessive), massive enlargement of the kidneys with compromised renal function
-cysts can also occur on other organs (liver, pancreas, spleen)
70
Q

Polycystic kidney disease is

A

painful due to distension of the cysts & stretching of fascia
-hemorrhage, rupture, or infection exacerbate this pain

71
Q

Most cases of polycystic kidney disease progress to

A

bilateral disease by adulthood

72
Q

PKD (poly cystic kidney disease) involves non-functioning

A

fluid filled cysts that range in size form microscopic to mass-effect producing size

73
Q

Complications of PKD include

A

hypertension due to activation of RAAS
cyst infections
bleeding
decline in renal function

74
Q

Treatment of PKD includes

A

symptoms management, dialysis, & transplant

75
Q

Wilms tumor often presents

A

unilaterally and a painless, palpable abdominal mass

<5% are bilateral

76
Q

Wilms tumor can be associated with

A

congenital/genetic malformations

Beckwith-Wiedemann, & WAGR

77
Q

The most common malignant renal tumor in children is

A

Wilms tumor

1/3rd occur in under age 1

78
Q

Wilms tumor treatment

A

requires resection & possibly chemotherapy
capacity for rapid cases
in cases of metastasis it is usually to the lungs

79
Q

Describe the stages of Wilms tumor

A

1- 43% of cases, limited to the kidney & is completely excised
2- 23% of cases, tumor extends beyond the kidney but is completely excised
3- 20% of cases, inoperable primary tumor lymph node metastasis
4- lymph node metastases outside of the abdominopelvic region
5- bilateral renal inolvement

80
Q

Describe a total nephrectomy

A

the renal artery & vein are ligated and then it involves removal of the kidney, the ipsilateral adrenal gland, perinephric fat, and the surrounding fascia
-the other kidney needs to be functional

81
Q

Describe a partial nephrectomy

A

(nephron-sparing surgery) is considered for patients with a solitary functional kidney, small lesions (<4cm), or bilateral tumors or for patients with increased risk because of other disease such as diabetes or hypertension

82
Q

Prior to surgery for nephrectomy

A

patients have flank mass
hypertension- started on anti-hypertensives
US & CT
Biopsy- diagnosis

83
Q

Anesthesia for nephrectomy include

A

premed
inhalation induction with peds, IV induction with adults
BP control- wide fluctuations requiring volume & vasopressors
PIVs x 2, aline, CVC placed by surgeon if chemo or by anesthesia for IV immunosuppression medication

84
Q

Additional anesthetic considerations for nephrectomy include

A 
standard risk assessment
identify smoking and age risk factors
note any preexisting renal dysfunction
many are anemic- CBC, T&C
K+-BMP
regional anesthesia include blockage of nerve roots T8-L3
ERAS
opioid sparing
85
Q

This is released by kidney in response to anemia, hypoxia

A

erythropoietin

86
Q

PTH causes increased _________ in exchange for phosphate

A

Ca2+ reabsorption

87
Q

________ is secreted from adrenal cortex and causes reabsorption of Na+

A

aldosterone

88
Q

_______ will constrict efferent arteriole & reabsorption of water

A

ADH/vasopressin

89
Q

___________ is released due to atrial distension (fluid overload) and stimulates excretion of Na+ and water

A

ANP

90
Q

______ causes vasodilation and Na+ excretion

A

dopamine- DA1 receptor

NRP511 (23 decks)

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