Renal/Urinary/ECT/RAAS Flashcards

Question

HypoK+ supplemetation wtih CKD

Answer 1

if hypokalemia is refractory to aggressive supplementation, additional electrolyte abnormalities (e.g., hypomagnesemia, hypocalcemia) and/or endocrinopathies (e.g., hyperaldosteronemia) should be investigated

Answer 2

optimized to achieve both optimal caloric and limited protein/phosphorus intake.

Answer 3

the low sodium content of renal diets can predispose patients to severe hyponatremia and neurologic sequelae if large volumes of water are administered after being blended with the diet

Answer 4

-- patient’s ability to synthesize and secrete endogenous erythropoietin is impaired -- erythropoiesis stimulating agent (ESA) may be indicated -- Darbepoetin α is hyperglycosylated, which prolongs the circulating half-life of the molecule and may reduce immunogenicity -- Adequate iron stores are necessary for an optimal response, and iron administration usually is required

Answer 5

-- phosphate binding drug for hyperphosphatemia -- Hypertension can be managed with amlodipine with or without ACE inhibitor

Answer 6

-- cats with stage II to III CKD, without concurrent illness or infection. -- should be considered before end-stage CKD, rather than as an emergency or salvage procedure -- free of other disease conditions including advanced primary cardiomyopathy, feline leukemia virus/feline immunodeficiency virus (FeLV/FIV), recurrent urinary tract infections, uncontrolled hyperthyroidism, and underlying neoplasia.

Answer 7

-- Cyclosporine prevents the activation of a number of transcription factors that regulate cytokine genes with a role in allograft rejection, including interleukin 2 (IL-2), IL-4, interferon γ (IFN-γ), tumor necrosis factor-α (TNF-α), and granulocyte-macrophage colony-stimulating factor (GM-CSF) -- Corticosteroids also inhibit these cytokines

Answer 8

Determined by amount of H2O contained in tub filtrate @ renal pelvis ADH (posterior pituitary gland) Aldosterone (adrenal cortex)

Answer 9

--Acts on DCT/Collecting Ducts --Promotes H2O reabsorption →prevent H2O loss --W/o ADH H2O will be lost in urine

Answer 10

--↑ reabsorption of Na+ from DCT/collecting ducts into bloodstream --Osmotic imbalance makes H2O follow Na+ into bloodstream *must be sufficient ADH present

Answer 11

RAAS responds to hypotension --Afferent glom. art have juxtaglomerular cells = monitor BP --Macula densa = cells in ALOH monitor NaCl concentration in filtrate → less NaCl will activate Renin

Answer 12

Enzyme that facilitates splitting of Angiotensin I from *Angiotensin*

Answer 13

Angiotensin -converting-enzyme --Converts Angiotensin I to Angiontensin II --Angiontensin II → causes arterial constriction to directly ↑ BP --Stimulates Aldosterone release

Answer 14

--Pre-renal: ↓ blood flow to kidneys = dehydration/CHF/shock --Renal Uremia: inability of kidneys to regulate urine production = not enough functional nephrons --Post-Renal: obstruction preveting urine from being expelled

Answer 15

Creat: < 1.4/<1.6 SDMA: < 18 UPC: < 0.2 BP: < 140

Answer 16

Creat: 1.4 - 2.8 SDMA: 18-35 UPC: Border 0.2- 0.5 BP: Pre 140 - 159 ## Footnote Tx; same as stage 1, renal theraputic diet; tx hypoK+ in cats; address nausea/inappetance

Answer 17

Creat: 2.9 - 5.0 SDMA: 36 - 54/ 26 - 38 UPC/BP varies on stage ## Footnote Same as stage 1-2; maintain Phos < 5; tx acidosis/+/- anemia; SQF

Answer 18

Creat: > 5.0 SDMA: > 54/ >38 ## Footnote same as 1-3; keep Phos < 6; consider feeding tube

Answer 19

Excessive urinary electrolyte-free water (free water) loss --Dilute PU --Obligate PD --**Central:** insufficient or absent circulating arginine vasopressin (AVP) --**Nephrogenic:** reduced or absent receptor response to circulating AVP ## Footnote Central tx: DDAVP Nephrogenic tx: Thiazide diuretics

Answer 20

--exacerbates glomerular capillary hypertension --contributes to progression of CKD via glomerulosclerosis and tubulointerstitial fibrosis --Leads to proteinuria

Answer 21

Aquaporins are channels that allow water to move from the tubular lumen into the renal tubular cell

Answer 22

**LOH and DCT** are the main sites of magnesium reabsorption in the kidney -- kidney is the main regulator of serum magnesium concentration and total body magnesium content -- regulation is achieved by both glomerular filtration and tubular reabsorption

Answer 23

kidney has the ability to excrete large quantities of bicarbonate, such that metabolic alkalosis should be rectified rapidly. When metabolic alkalosis is persistent, there must be factors limiting renal bicarbonate excretion

Answer 24

1. Decreased effective circulating volume 2. hypochloremia can both limit renal bicarbonate excretion. 3. Hypokalemia and 4. aldosterone excess further impair renal bicarbonate excretion

Answer 25

Hypovolemia stimulates baroreceptors that cause the hypothalamic-pituitary-adrenal axis to produce and release ADH, aldosterone, renin, and cortisol

Answer 26

overexpansion of the cardiovascular system causes stretch of the atria and release of atrial natriuretic peptide = increase in renal water/Na+ excretion — RAAS countermeasures

Answer 27

wide spectrum of disease ranging from clinically undetectable, subcellular damage to fulminant, excretory failure that leads to retention of uremic toxins and dysregulation of fluid, electrolyte, and acid-base balance -- typically multifactorial: overlapping ischemic, inflammatory, toxic, and septic components.

Answer 28

Nonazotemic AKI: 1. Creat = < 1.6 1. Documented AKI 1. nonazotemic increase in serum creatinine ≥0.3 mg/dl w/i 48 hrs 1. Measured oliguria (<1 ml/kg/hr) or anuria over 6 hours

Answer 29

Mild AKI: 1. Creat = 1.6–2.5 1. Documented AKI and static or progressive azotemia 1. azotemic increase in serum creatinine ≥0.3 mg/dl (≥26.4 μmol/L) within 48 hours, 1. Measured oliguria (< 1 ml/kg/hr) or anuria over 6 hours

Answer 30

Moderate to Severe AKI: 1. Creat = 2.6–5.0 1. Documented AKI and increasing severities of azotemia and functional failure

Answer 31

Stage 4 = Creat = 5.0–10.0 Stage 5 = Creat > 10

Answer 32

hemodynamic (prerenal), renal parenchymal (intrinsic), postrenal causes.

Answer 33

Hemodynamic causes include decreases in renal perfusion or excessive vasoconstriction and are characterized as rapidly reversible if the inciting cause is eliminated. However, prolonged ischemia can contribute to renal parenchymal injury

Answer 34

intrinsic causes of AKI include infectious diseases, toxins, or systemic diseases with renal manifestations.

Answer 35

due to obstruction or diversion of urine flow, including urethral obstruction, bilateral ureteral obstruction, unilateral obstruction with a nonfunctional contralateral kidney, or rupture of any portion of the urinary tract. --prolonged obstruction of urine flow may lead to renal parenchymal injury

Answer 36

USG = isosthenuric (1.007 to 1.015) -- urine pH is usually acidic, unless there is a concurrent bacterial urinary tract infection (caused by a urease-producing organism) -- urine sediment may disclose dysmorphic red blood cells (suggestive of glomerular disease), pyuria, or casts (most frequently granular)

Answer 37

-- hematocrit may be increased from hemoconcentration or decreased from gastrointestinal blood loss or hemolysis -- suspect infectious with leukocytosis -- severity of azotemia depends on the cause and duration -- anion gap is usually high secondary to retained organic and inorganic acids that the injured kidney is unable to excrete

Answer 38

-- with tubular function compromised, the ability to reabsorb bicarbonate and excrete hydrogen ions is diminished. -- Lactic acidosis secondary to compromised tissue perfusion also may contribute to altered blood pH.

Answer 39

modalities in which blood is removed from patient circulation and processed before being returned to the patient. During processing, blood can be cleared of endogenous and exogenous substances, and beneficial substances can be added to the blood.

Answer 40

1. acute kidney injury (AKI) 1. treatment of intoxications and poisonings 1. rarely for fluid removal in refractory congestive heart failure.

Answer 41

1. intermittent hemodialysis (IHD) 2. continuous renal replacement therapy (CRRT), 3. prolonged intermittent renal replacement therapy

Answer 42

hybrid therapy where hemodialysis is performed over prolonged periods of time (6 to 12 hours), rather than shorter periods in IHD or continuously as with CRRT. -- safely provide solute removal and decrease the risk for hemodynamic instability and other complications that can occur with more rapid treatment, while allowing a veterinary hospital to provide care without overburdening the veterinary team

Answer 43

uses the large peritoneal surface area as a natural “dialysis membrane” and is not an extracorporeal therapy because blood is never outside the patient’s body. -- PD can be performed without a dialysis machine. -- relies on solute removal via diffusion and convection -- dialysate in the peritoneal cavity equilibrates with the blood compartment through the peritoneal membrane and peritoneal capillaries

Answer 44

the movement of solutes between two aqueous solutions separated by a semipermeable membrane. -- two major factors that contribute to solute movement are **diffusion** and **convection**

Answer 45

depends on the concentration gradient between the two compartments, the solute charge and molecular weight, and the surface area and permeability of the membrane -- BUN and Creat are low molecular weight molecules that freely diffuse across dialysis membrane ## Footnote Diffusion utlized by IHD treatment

Answer 46

solutes are dragged with plasma water across the dialysis membrane as a result of an osmotic or hydrostatic pressure gradients (solvent drag). -- Convection allows for effective removal of middle molecular weight solutes and small amounts of large molecular weight solutes during dialysis, if membrane pores are of sufficient size ## Footnote CRRT utilizes conective solute removal

Answer 47

dictated by amount of water movement across the membrane, the membrane pore size, and the membrane surface area.

Answer 48

Fluid movement driven by hydrostatic pressure gradients prescribed to treat hypervolemia -- Fluid removal from a patient to correct fluid overload; solutes will be removed; however, -- pressure gradient results from either positive or negative **osmotic pressure caused by non‐permeable solutes.** This leads to the removal of “plasma water” from the blood and produces a fluid referred to as the ultrafiltrate (UF) **ultrafiltration is prescribed for the purpose of treating fluid overload**

Answer 49

Bulk flow of solutes dragged across a semipermeable membrane with water movement by hydrostatic or osmotic pressure gradients -- Removal of small, medium, and large MW solutes -- Convection is the movement of solutes with water flow ## Footnote CRRT example

Answer 50

Diffusive movement of solutes from a region of high concentration to a region of lower concentration across a semipermeable membrane -- Removal of small and some middle molecular weight (MW) solutes ## Footnote IHD example

Answer 51

-- Severe hypotension, -- Severe preexisting coagulopathies -- peritonitis, recent abdominal or thoracic surgery, hypoalbuminemia, and severe hypercatabolic states

Answer 52

-- Rapid removal of osmotically active solutes (primarily BUN) from the blood compartment creates temporary acute osmotic pressure gradients between the blood, extravascular, and intracellular compartments. -- gradient can allow plasma water to shift from the vascular compartment and into the intracellular compartments. When this phenomenon occurs in brain tissue, secondary swelling occurs, and this can lead to irreversible neurologic damage or death -- initial treatments are prescribed to achieve slow solute removal, with lower rates of urea reduction; this allows redistribution of osmotically active solutes between fluid compartments to occur before large osmotic pressure gradients develop.

Answer 53

1. hypotension, 1. hemorrhage secondary to systemic heparinization (which can occur internally such as in the lungs or GI tract and not be readily visible), 1. hypocalcemia or alkalemia from regional citrate anticoagulation, 1. dialysis disequilibrium syndrome, 1. air embolism, 1. dialyzer membrane reaction, 1. blood loss through clotting of the extracorporeal circuit, 1. catheter occlusion.

Answer 54

ECT in which blood is removed from patient circulation, the blood is separated into its components, and one or more of the components is removed or processed before the blood is returned to the patient. ## Footnote Example TPE

Answer 55

apheresis treatment in which the plasma component of blood is removed and replaced with a replacement solution such as a colloid solution or a combination of crystalloid and colloid solutions before being returned to the patient -- combinations of saline, hetastarch, and fresh-frozen plasma are used for replacement

Answer 56

First-line therapy acute, short-term therapy for moderate to severe myasthenia gravis (MG) or hyperviscosity from hypergammaglobulinemia.

Answer 57

second-line therapy (e.g., severe immune-mediated hemolytic anemia [IMHA])

Answer 58

immune thrombocytopenia or sepsis with multiorgan failure) is one where controlled trials are limited or results are inconclusive

Answer 59

condition where apheresis is considered ineffective or harmful.

Answer 60

prescribed apheresis treatment plans. The ability to remove a substance successfully during TPE depends on the distribution of the substance within the body (the volume of distribution), the rapidity with which the substance equilibrates between body compartments, and the ability to remove adequate amounts of the pathologic substance -- most successful treatments are achieved with substances that have a small volume of distribution (and are located primarily in the intravascular space) because removal is occurring directly from the intravascular space.

Answer 61

pathologic substances such as: antibodies, immune complexes, cytokines, and by these means, can alleviate or improve manifestations of some immune-mediated diseases

Answer 62

drug overdoses and toxicities, particularly nonsteroidal antiinflammatory drug (NSAID) overdoses, where the **drug is largely protein bound** and therefore distributed largely in the intravascular space

Answer 63

-- has been shown to decrease antibody, immunoglobulin concentrations -- dogs that have not responded to 4 or more days of appropriate immunosuppressive therapy or incompatible to crossmatches --

Answer 64

-- cases refractory to medical management or in patients with rapidly progressive, severe disease, TPE might improve outcomes.

Answer 65

-- severe signs of hepatic encephalopathy -- severe hyperbilirubinemia, and neurologic signs suspected to be secondary to severe hyperbilirubinemia

Answer 66

1. Volume of toxin distribution 2. degree toxin is protein bound 3. molecular weight of toxin

Answer 67

1. blood flows through the extracorporeal circuit and across a hemodialyzer. 1. dialyzer is composed of thousands of semipermeable straws. 1. patient’s blood passes through the hemodialyzer straws, while a contrived dialysate solution passes in a countercurrent direction. 2. dialysate solution may be augmented depending on the intoxication to either prevent the development of electrolyte disturbances or prevent ongoing metabolism of the toxin.

Answer 68

primary method of clearance is via convection. -- solvent is removed by augmenting the transmembrane pressure across the dialyzer. As the solvent is removed, solute clearance occurs via solvent drag

Answer 69

Achieves Adsorptive clearance -- more effective at removing larger molecules -- blood is perfused across a charcoal or adsorbent polymer cartridge -- toxin will reversibly bind and be removed from circulation

Answer 70

-- purpose of a blood prime is to prevent hemodilution and maintain adequate tissue oxygenation during the initial stages of treatment. -- Priming with packed red blood cells is most typically used in anemic patients or in cats and small dogs because of their smaller blood volume

Answer 71

-- purpose of this step is to remove any substances that may remain in the tubing. The flow during this stage is quite rapid and this will also help remove air from the circuit. -- At the end of the recirculation stage, the prescribed treatment rates are set and the patient is connected to the dialyzer for the treatment stage

Answer 72

1. ethylene glycol 1. propylene glycol 1. barbiturates 1. cannabinoids 1. methotrexate 1. NSAID 2. aspirin 3. alcohols 4. theophyllines 5. antianxiety medications

Answer 73

100 mmHg, for both dogs and cats

Answer 74

55 mmHg in dogs and 59 mmHg in cats -- pressure within the glomerular capillary is substantially higher than the pressure within Bowman’s space, thus leading to a difference in hydrostatic pressure of 35 mmHg = rapid filtration

Answer 75

-- continues to reabsorb sodium and chloride as well as calcium and magnesium after PCT -- requires an active transport mechanism -- Very little water is reabsorbed in the loop of Henle as the cells are relatively impermeable to water -- reabsorption of sodium, without reabsorption of water, causes a dilution of the filtrate and a hyposmotic fluid

Answer 76

**65% occurs in PCT** --80% of H20/Na+/Cl-/HCO3 reabsorped --100% Glucose/AA **uses active transport** -- while water moves passively along the concentration gradient as solutes move out of the tubule lumen and into the tubular cells

Answer 77

-- relatively impermeable to water but continues to reabsorb sodium and chloride. -- Parathyroid hormone acts on the distal tubules to regulate calcium and Mg++ reabsorption

Answer 78

fluid reaching the collecting duct is hyposmotic to plasma with an osmolality of approximately 100 mOsm/kg -- antidiuretic hormone (ADH), released from the posterior pituitary, influences the collecting ducts begin to reabsorb water -- Without ADH, the collecting ducts are relatively impermeable to water.

Answer 79

an animal that can maintain (MAPs) of 80–100 mmHg, the kidney can maintain a constant RBF and GFR that varies less than 10% -- resulting in constriction or dilation of the afferent or efferent arterioles in response to varying mean arterial pressures

Answer 80

abnormal concentration of urea nitrogen and creatinine in the blood. related to a diminished capacity of the kidney to remove these substances, but equally as common, it can be related to conditions that affect the volume of blood reaching the kidneys, or impaired outflow of urine ## Footnote Pre, Renal, Post

Answer 81

-- failure of blood supply to reach the glomerulus and subsequent reduction of solutes that move through the nephron. -- conditions affecting intravascular volume such as 1. hypovolemic shock 2. third space losses 3. decreased cardiac output, 4. high‐protein diet, 5. gastrointestinal bleeding -- Prolonged ischemia may result in damage to the renal parenchyma, thus causing intrinsic kidney injury

Answer 82

impediment to the flow of urine out of the body, or redirection of urine flow. -- urethral obstruction in the male cat; other examples include ruptured or herniated bladder, ruptured urethra, urinary blockage from neoplasia of the urethra, bladder, or surrounding tissues, prostatic disease, and ureteroliths

Answer 83

-- feline interstitial cystitis, crystaluria, urolithiasis, neoplasia, stricture, and, uncommonly, urinary tract infection -- relieve obstruction, treat hypovolemia/shock, electrolyte and pH abnormalities,

Answer 84

-- extreme polyuria following relief of obstruction -- high IVF rates may be needed to prevent dehydration until kidneys can regulate again

Answer 85

CAUTI can arise via either intraluminal (through the inside of the catheter) or extraluminal (along the outside of the catheter) means

Answer 86

measurement of the hydrostatic pressure in the intrathoracic vena cava, and estimates right atrial pressure (RAP) ## Footnote euvolemic patients is approximately 0–5 cmH2O

Answer 87

Exposure to the spirochete Borrelia burgdorferi from deer tick *Ixodes scapularis* -- suspected in Lyme-seropositive PLN cases (Lyme+ PLN) in endemic regions