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Renal Week 3 Flashcards

1
Q

Chronic kidney disease: definition

A

Permanent reduction in GFR for at least 3 months

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2
Q

Stages of CKD

A

1: >90 GFR w/ evidence of kidney damage
2: 60-89 GFR w/ evidence of kidney damage
3: 30-59 GFR - mild CKD
4: 15-29 GFR - moderate CKD
5:

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3
Q

Common causes of CKD

A 
Diabetic nephropathy
HTN nephrosclerosis
GN
PKD
Interstitial dz
Obstruction
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4
Q

Clinical signs of CKD

A

Anemia (stage 2)
HTN (tx ASAP, stage 1)
Bone/mineral disorders

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5
Q

4 components of anemia in CKD

A

Decreased EPO
Decreased RBC survival
Increased bleeding risk
Bone marrow space fibrosis

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6
Q

3 reasons for HTN in CKD

A

Expansion of ECF volume
Increased RAS activation
Autonomic dysfunction

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7
Q

Water/sodium balance in CKD

A

Can concentrate/dilute urine
200-300 mOsm
Increase in intake = edema
Decrease in intake = volume depletion

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8
Q

Potassium balance in CKD

A

Decreased kidney excretion -> increased fecal excretion

Therefore hard to clear K+ quickly

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9
Q

How much acid is normally generated every day?

A

1 meq/day

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10
Q

3 forms acid is excreted

A

NaPO4 (titratable acids)
H+ (via Aldosterone)
NH4+ trapping

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11
Q

Which forms of acid excretion change with CKD?

A

H+

NH4+ -> less nephrons making NH3, acidosis seen with >25% decrease from normal (stage 3 ish)

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12
Q

Ca2+ and Pi

A

High Pi triggers FGF-23 -> inhibit 1,25 vit D
Low Ca triggers PTH release
Chronically elevating levels of PTH
Low Vit D (stage 2 ish)

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13
Q

Intact Nephron Hypothesis

A

Functioning nephrons maintain glomerulotubular balance

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14
Q

Magnification Phenomenon

A

Remaining nephrons magnify their excretion of a given solute

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15
Q

Trade-off Hypothesis

A

Increased PTH for normal Ca2+ levels

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16
Q

Creatinine balance in CKD

A

Excretion must remain constant

With decreasing GFR, elevation in serum Cr

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17
Q

Progressive disease characteristics in CKD

A

Glomeruli hypertrophy
Blood flow per nephron increases
Intra-glomerular pressure increases
Solute flow per tubule increases

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18
Q

Treatments for CKD

A

Eval cause/eval CVD risk
Control BP and reduce risk factors (stage 1)
Restrict diet phos, phos binders, Vit D (stage 2)
Select site for dialysis and preserve veins (stage 3)
Place AVF (stage 4)
Dialysis/transplant (stage 5)

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19
Q

Indications for dialysis

A

Volume overload while on diuretics
Hyperkalemia
Uremic pericarditis
Uremic symptoms

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20
Q

Uremic symptoms

A

Lethargy, difficultly concentrating (early)
Coma/seizures (late)
Nausea, decreased appetite
Uremic bleeding

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21
Q

Types of dialysis

A

Hemodialysis
Frequent/nocturnal dialysis (night, at home)
Peritoneal dialysis

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22
Q

Types of access for hemodialysis

A

AV fistula
AV graft
Double lumen catheter (tunnel cath in IJ to SVC)

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23
Q

Types of peritoneal dialysis

A

Continuous ambulatory PD - drain manually
Continuous cycling PD - machine at night, leave dialysate
Nocturnal intermittent PD - same, don’t leave dialysate

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24
Q

Complications of peritoneal dialysis

A

Infection, scarring, cath dysfunction
Hernias
Metabolic: hyperG, hyperL, hypokalemia

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25
Warm vs. cold ischemia
Warm: death/clamp to cold perfusion (60 min) Cold: Cold perfusion to @ (24-36 hours)
26
Direct vs indirect rejection
Direct: R Tcells to intact D HLA antigens (transplant only) Indirect: R Tcells to fragments D HLA (normal)
27
Immune signals
Tcell CD3 R w/ MHC complex -> PLC -> Ca2+ release -> Calcineurin activity -> dephos NFAT -> enters nuc -> IL-2 (Co-stimulatory CD28 binding) IL-2 proliferation of CD4 (Th1 and B cells) and CD8 (attack)
28
T and B cell rejection
T cell: tubulitis (Banff I) or vasculitis (Banff II) | B cell: antibody mediated, complement
29
Immunosuppression regimen in transplant
1st: calcineurin inhibitor (cyclosporine, tacrolimus) - SE nephrotox, HTN, diabetes 2nd: proliferation inhibitor (MMF, sirolimus) 3rd: prednisone
30
AKI eval in transplant
Pre-renal (volume down, renal artery thrombosis, calcineurin tox) Renal (delayed graft/function, acute rejection, recurrent primary dz, infection) Post-renal (obstruction)
31
Routes of infection for UTI
Ascending (more common, ex fecal flora E.coli) | Bloodborne (less common, often ureteral obstruction/immunosuppression)
32
Virulence factors in UTI
``` Bacterial adhesion O Antigens (hard to tx) Endotoxin (decrease ureteric peristalsis) ```
33
Host defense mechanisms against UTI
Mechanical (peristalsis, flow) Chemical (prostatic secretions, pH, ammonia, P1 BG Ag) Immune (IgA, complement) Cellular (PMNs)
34
Complications of UTI
``` Acute pyelonephritis Perinephric abscesses Scarring Recurrence Stones ```
35
Vesico-ureteral reflux
No valve, but oblique course in wall Reflux with perpendicular entry - backflow of urine Primary (congenital) vs. secondary (neurogenic bladder)
36
Factors for stones
``` HyperCa Increased uric acid low pH low volume Bacteria ```
37
Acute pyelonephritis and consequences
PMNs in interstitium WBC, WBC casts microabcesses, perinephric abscess Can lead to pap nec, urosepsis
38
Chronic pyelonephritis and consequences
ESKD Irregularly scarred, atrophy, periglomerular bifrosis + reflux = secondary FSGS, poor prognosis
39
Renal papillary necrosis
Gross hematuria and proteinuria | Sickle cell, Acute pyelonephritis, Analgesics, DM
40
Benign tumors of the kidney
Renal papillary adenoma(small, well circumscribed in cortex) Angiomyolipoma (vessels, SM, fat, often w/ TS) Oncocytoma (eosinophilic epithelial cells, lots of mito)
41
Malignant tumors of kidney
``` Renal cell carcinomas: Clear cell Papillary (chromophillic) Chromophobic Collecting (Bellini) duct Familial RCC ```
42
RCC Clear Cell
``` Most common (80%) Hematuria, ball like mass Can extend renal cortex -> vein -> heart Often single (unless familial) Spherical, focal hemorrhage Types on micro: clear, granular, spindle ```
43
Papillary Carcinoma
Often multifocal Papillary growth pattern Better prognosis than clear cell
44
Chromophobic Carcinoma
Prominent cell membranes Halo around nucleus Similar to oncocytoma (from intercalated cells) Excellent prognosis
45
Familial RCC
VHL: often bilateral and multifocal, hemangioblastomas of cerebellum and retina Hereditary CCC: confined to kidney, same genes as VHL Hereditary papillary carcinoma: AD, multiple bilateral with papillary histology (MET mutation)
46
Familial vs. sporadic
``` Hereditary = multifocal Sporadic = single ```
47
Urothelial carcinomas
Renal pelvis to urethra M>F, >50yrs Schistosomiasis
48
Two functions of bladder and dysfunction symptoms
``` Storage phase (frequency, uregency, incontinence) Emptying phase (hesitancy, weak stream, incomplete emptying) ```
49
LUT Innervation
``` T10-L2 = sympathetic, hypogastric nerves S2-S4 = parasympathetic, pelvic nerves S2-S4 = somatic, pudendal nerves ```
50
Micturition cycle
1. Increase in wall tension 2. Afferent input to pontine micturition center/cortical egress 3. Pudendal nerve activity ceases, relaxation and detrusor neurons freed 4. Proximal urethra opens Bladder immediately contracts
51
Types of incontinence
Stress: F (post child), alpha-agonists Urgency: frequency/nocturia, anti-chol drugs
52
LUT obstruction in men
Most common: BPH 80% or 80 y/o have, 50% with symptoms Tx: alpha-blocker Younger men: urethral stricture (trauma)
53
3 parts of embryonic kidney and destiny
Nephrogenic cord (in urogenital ridge) gives rise to: Pronephros - degenerates by 4 weeks Mesonephros - uteric bud, ureters -> collecting tubules Metanephros - blastemia, SVT to capillary
54
Two ducts and destiny
Mesonephric duct - Wolffian duct | Paramesonephric duct - Mullerian duct
55
Urogenital sinus
From caudal portion of endoderm = cloaca Allantosis (part of sinus) becomes urachus Sinus becomes bladder and urethra
56
Renal agenesis and hypoplasia
Failure of metanephric to develop or early degeneration | Unilateral more common (associated with 1 umbilical artery)
57
Renal dysplasia
Abnormal differentiation of metanephric tissue | Presents w/in first decade
58
Renal ectopia
Failure of kidney to rise or rotate | Can lead to uteral obstruction or discoid kidney
59
Horseshoe kidney
Failure to separate along midline (90% lower pole) | Ureters exit anterior, stones likely
60
3 classifications of pediatric cystic kidney disease
Acquired Genetic (AD or AR PKD) Developmental (MCDK)
61
ADPKD
``` PKD1 (16p13) - 90%: manifests earlier (Adult) PKD2 (4q21) - 10% (Adult) Cystic dilations in ALL parts of nephron Can be spontaneous, 100% penetrant HTN, CRF, ESKD (50%) ```
62
ARPKD
PKHD1 (6p21) - Infantile Early onset HTN, can't concentrate urine Cysts are dilations in collecting tubules
63
ADPKD organs vs. ARPKD organs
ADPKD: Liver/pancreas cysts, cerebral aneurysms ARPKD: Fibrous expansion of portal tracts, bile duct prolif
64
MCDK
Abnormal induction of metanephros Ureteral or uteropelvic atresia Non-function and involuted over time kidney
65
Congenital mesonephric blastoma
``` Prenatal sonogram = ring sign Fibrotic, firm mass Non-cellular = bengin Cellular = ETV6-NTRK3 fusion (kinda aggressive) Often with trisomy 11 ```
66
Wilms tumor
Claw sign Triphasic: blastemal, epithelial, stromal Anaplasia present = unfavorable Rarely bilateral - instant stage 5
67
Wilms genetics
WT-1 11p13: intralobar rests (WAGR) | WT-2 11p15: perilobar rests (BW syndrome)
68
Ureteral duplication
Both enter ipsilaterally Reflux into lower pole Obstruction in upper pole (ureterocele)
69
Megalocystis
Chronic abnormal distention of bladder due to obstruction
70
Posterior urethral valves
Obstruction of posterior male urethral valves (ab insertion of mesonephric duct on cloaca)
71
Epispadias and hypospadias
Meatus on dorsal or ventral side of penis
72
Chordee
Fibrous band causing curve of penis
73
Potter sequence (consequences of obstruction/agenesis)
Large flattened ears/nose Infraorbital skin folds Amnion nodosum (skin cells on placenta) Pulmonary hypoplasia (less fluid in lungs to expand)
74
Prune belly (Eagle-Barrett)
Mostly males, atrophy of anterior abdominal muscles Undescended testes Develop megalocystis

CVPR (5 decks)

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