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2 Review Course > Kidney, Liver Pancreas > Flashcards

Kidney, Liver Pancreas Flashcards

1
Q

What level of the vertebral column do the kidneys lie?

A

T12-L3

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2
Q

What is the fatty tissue the kidneys lie in called?

A

perirenal fat.

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3
Q

What is the medial concave margin of the kidneys called?

A

Hilus (artery, vein, nerves, lymphatics and ureters enter here)

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4
Q

What gives the renal pyramids a striated appearance?

A

loop of henle and collecting ducts

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5
Q

What is the apex of each renal pyramid?

A

papilla

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6
Q

What do the papilla empty into?

A

minor calyx then major calyx then renal pelvis

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7
Q

What is the major reservoir for urine?

A

renal pelvis

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8
Q

What is the functional unit of the kidney?

A

nephron

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9
Q

Where does the formation of urine begin?

A

nephron

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10
Q

What structures are in the renal cortex?

A

bowman capsule, glomerulus, proximal tubule, distal convoluted tubule

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11
Q

What structures are in the medulla?

A

Loop of henle

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12
Q

Which type of nephrons lie deep in the cortex and play an important role in concentration of urine?

A

juxtamedullary

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13
Q

What percentage of CO do the kidneys receive?

A

20-25%

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14
Q

After leaving the peritubular capillaries, what is the order blood flows back into renal veins?

A

peritubular capillaries -> interlobular ->arcuate -> interlobar -> lobar -> renal veins

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15
Q

The cardiac output portion that passes through each kidney is called what?

A

renal fraction

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16
Q

What is the renal fraction of a 70kg man?

A

21%

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17
Q

What is the equation of renal blood flow?

A

(MAP-VP) x VR

VP is venous pressure and VR is vascular resistance

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18
Q

Renal blood flow is autoregulated between what MAP values?

A

50-180

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19
Q

What mechanisms are responsible for renal auto regulation?

A

afferent arteriole vasodilation, myogenic mechanisms

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20
Q

How does a reduction in glomerular filtration affect the afferent arterioles?

A

dilation. glomerular filtration and renal blood flow have a direct relationship

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21
Q

What types of nerves innervate the afferent and efferent arterioles?

A

sympathetic

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22
Q

What are the three major tasks of the kidneys to maintain homeostasis?

A

filtration, reabsorption, and tubular secretion

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23
Q

What is the first step to the formation of urine?

A

filtration

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24
Q

If the GFR is 125mL/min and the renal blood flow is 650ml/min, what is the filtration fraction?

A

19%

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25
Q

Glomerular filtration rate is dependent on what three things?

A

pressure inside the glomerular capillaries, pressure in the bowman capsule, colloid osmotic pressure of the plasma proteins

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26
Q

What pressure tends to hold fluid within the glomerulus?

A

colloid osmotic pressure created by proteins

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27
Q

What pressure opposes filtration?

A

Pressure in the Bowmans capsule

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28
Q

What is the normal filtration pressure in the glomerulus?

A

10mmHg

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29
Q

What factors increase GFR? (3)

A

increased renal blood flow, dilation of afferent arteriole, constriction of efferent arteriole

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30
Q

What structure regulates GFR?

A

juxtaglomerular complex

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31
Q

Glomerular filtrate is similar to plasma, except that it lacks significant amount of what?

A

proteins. glomerulus is almost impermeable to all plasma proteins

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32
Q

Where is 99% of plasma filtrate reabsorbed?

A

nephron

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33
Q

What type of active transport requires energy?

A

primary active transport

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34
Q

What is passive transport?

A

movement of substances across membranes and relies on either concentration gradients or chemical gradients

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35
Q

Most primary active transport is for what ion?

A

Sodium

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36
Q

What ions are exchanged in the process of counter transport?

A

Hydrogen and potassium are secreted in exchange for sodium

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37
Q

What are 2 substances that are passively absorbed?

A

chloride and urea.

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38
Q

What is the primary function of the proximal tubule?

A

active transport of sodium

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39
Q

What is the process by which proteins are able to be reabsorbed.

A

Pinocytosis. Tubular membranę engulfs the protein, digested into amino acids and then reabsorbed into interstitial fluid

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40
Q

What is the primary function of the loop of henle?

A

establish a hyper osmotic state within the medulla area of the kidney. conserve salt and water

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41
Q

In the late distal tubule, sodium under the influence of ____, is reabsorbed.

A

aldosterone

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42
Q

What part of the nephron determines the final degree of urine acidification?

A

late distal tubule

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43
Q

The permeability of water in the collecting duct is determined by what hormone?

A

ADH

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44
Q

Any condition that causes the quantity of oxygen transported to the tissues to decrease stimulates the release of what glycoprotein?

A

erythropoietin

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45
Q

What mineralocorticoid causes the reabsorption of sodium and water in the distal segments of the nephron?

A

aldosterone

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46
Q

What is the strongest trigger of aldosterone release?

A

potassium cx in the extracellular fluid

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47
Q

Release of ADH is controlled by what mechanism?

A

osmotic concentration of the extracellular fluids

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48
Q

What inhibits ADH release?

A

stretch of atrial baroreceptors

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49
Q

What are stimuli for the release of renin?

A

beta-adrenergic stimulation, decreased perfusion to afferent arteriole, reduction in Na delivered to the DCT.

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50
Q

What peptide hormone antagonizes the release of renin, aldosterone, and ADH?

A

atrial natriuretic factor

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51
Q

What is the most potent diuretic? It’s trigger for release is atrial distention, stretch or pressure.

A

atrial natriuretic factor

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52
Q

What alterations in serum creatinine are diagnostic of kidney injury?

A

Absolute increase of 0.3mg/dL or 50% increase

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53
Q

Urine output of ____ for more than 6 hours is diagnostic of kidney injury.

A

<0.5 mL/kg/hr

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54
Q

What urine flow rates are characteristic of nonoliguric, oliguric and anuric?

A

Nonoliguric: >400mL/day
Oliguric: <400 mL/day
Anuric: <100 mL/day

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55
Q

What is the cause of prerenal AKI?

A

Hypoperfusion of the kidneys

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56
Q

What is the cause of intrinsic AKI?

A

Disease of the renal parenchyma

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57
Q

What is thr cause of postrenal AKI?

A

Acute obstruction of the urinary tract.

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58
Q

What is the most sensitive marker for AKI?

A

Serum creatinine clearance

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59
Q

What is one factor related to the liver that is an independent risk factor for AKI?

A

Elevated bilirubin

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60
Q

Aortic cross clamp in what direction (above/below) of the renal arteries increases the risk of AKI?

A

above the renal arteries

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61
Q

How can we reduce the risk of AKI from contrast dye?

A

minimize volume of dye given, hydration, diuresis

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62
Q

What is the most common cause of obstructive uropathy?

A

calculi or prostatic disease

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63
Q

What are key indicators in the development of AKI in septic patients?

A

hypovolemia, decreased pulmonary function, acidosis

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64
Q

What is the most common cause of AKI?

A

prolonged renal hypoperfusion

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65
Q

Which crystalloid is preferred to prevent aldosterone secretion, hyponatremia, and oliguria in the preoperative period?

A

0.9% Normal Saline

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66
Q

How does Fenoldopam work?

A

dopamine-1 receptor agonist causing renal arteriolar vasodilation.

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67
Q

What are 4 indications for renal replacement therapy?

A

hyperkalemia, hyperuremia, metallic acidosis, and fluid overload

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68
Q

What are the three interventions for the treatment of AKI?

A

administer volume, improve CO by decreasing afterload, normalize SVR

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69
Q

What are signs of pre renal AKI?

A

oliguria, high urine osmolality, low urine sodium

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70
Q

What stage of kidney disease is “Kidney damage with normal or increased GFR”

A

stage 1

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71
Q

What stage of kidney disease is “GFR 30 to 59 mL/min per 1.73 m2”

A

stage 3

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72
Q

What stage of kidney disease is GFR 15 to 29 mL/min per 1.73 m2

A

stage 4

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73
Q

What stage of kidney disease is GFR 60 to 89 mL/min per 1.73 m2 with evidence of kidney damage

A

stage 2

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74
Q

What stage of kidney disease is End-stage renal failure with GFR less than 15 mL/min per 1.73 m2

A

stage 5

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75
Q

Clinical signs of renal disease are absent until what percentage of functioning nephrons remain?

A

less than 40%

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76
Q

What drugs can cause interstitial nephritis and renal insufficiency?

A

aminoglycosides, NSAIDs, piperacillin

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77
Q

What two patient populations are at increased risk of contrast induced renal insufficiency?

A

creatinine > 1.2 and diabetics

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78
Q

Volume overload unresponsive to diuretic therapy, Persistent hyperkalemia despite medical treatment, Severe metabolic acidosis, Overt uremic symptoms, Encephalopathy, Pericarditis, and Uremic bleeding diathesis are all absolute indication for what type of therapy for kidney injury?

A

renal replacement therapy

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79
Q

Ultrafiltration is a technique in which hydraulic pressure difference across a semipermeable membrane causes bulk fluid removal and solute by what type of transport?

A

convective

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80
Q

continuous veno-venous hemofiltration, solute transport occurs by ______
continuous veno-venous hemodialysis, solute transport occurs by _______
continuous veno-venous hemodiafiltration, solute transport occurs by _____.

A

continuous veno-venous hemofiltration, solute transport occurs by convection
continuous veno-venous hemodialysis, solute transport occurs by diffusion
continuous veno-venous hemodiafiltration, solute transport occurs by convection and diffusion

81
Q

What are the two advantages of peritoneal dialysis?

A

no need for vascular access and no anticoagulation needed

82
Q

What is the most severe CNS effect of dialysis? what is it?

A

disequilibrium syndrome - rapid increase in brain intracellular volume d/t reduced serum Na and BUN.

83
Q

What are negative effects of the acetate in dialysis solution?

A

causes vasodilation and cardiac depression

84
Q

Is the incidence of hypotension during dialysis more common in patient who have fasted or ate a meal before dialysis?

A

Hypotension is less common in patients that fasted before dialysis.

85
Q

Substitution of acetate for _____ in the dialysate decreases the incidence of hypotension?

A

HCO3. Also reduced hypoxemia.

86
Q

What is the most common neuromuscular complication of dialysis?

A

muscle cramping. D/t decrease intravascular volume and reduced Na

87
Q

What medication relives muscle cramping from dialysis?

A

hypertonic saline

88
Q

What is the single most important source of information in establishing the presence or absence of renal disease?

A

medical history

89
Q

What does urine specific gravity measure and what is it a reflection of?

A

mesures renal capability to excrete concentrated or dilute urine. Reflection of tubular function

90
Q

What amount of excreted protein is diagnostic of proteinuria?

A

> 150mg of protein/day

91
Q

What lab values reflect renal tubular function?

A

urine specific gravity, urine osmolality, and urine sodium concentration

92
Q

What lab values evaluate GFR?

A

plasma creatinine clearance, creatinine clearance, and BUN

93
Q

What is the chief end product of protein metabolism?

A

Urea

94
Q

What is the normal BUN value?

A

10-20mg/dL

95
Q

What are the causes of different BUN levels?
BUN < 8:
BUN 20-40:
BUN > 50:

A

BUN < 8: over hydration, underproduction of urea
BUN 20-40: dehydration, high nitrogen, decreased GFR
BUN > 50: decreased GFR

96
Q

What is the relationship between creatinine levels and GFR?

A

creatinine levels are inversely related to GFR. A 50% reduction in GFR, doubles creatinine levels.

97
Q

What lab value is the most reliable assessment tool for renal function?

A

creatinine clearance

98
Q

What is the formula for creatinine clearance?

A

GFR = (urine creatinine x urine volume) x serum creatinine

99
Q

If the patient is anuric what formula can be used to calculate creatinine clearance?

A

Cockcroft-Gault.

GFR = ([140-Age] x wt in Kg) / (72 x serum creatinine)

100
Q

What is a normal creatinine clearance value?

A

95-150

101
Q

What is the most common cause of death in patients with chronic renal failure?

A

ischemic heart disease

102
Q

What metabolite of morphine has increased circulating levels in patients with kidney disease?

A

M6G leading to respiratory depression

103
Q

Which neuromuscular blocker is contraindicated in renal dysfunction?

A

Pancuronium

104
Q

Insensible fluid losses in dialysis patients should be replaced with which fluid?

A

5-10mL/kg of D5W

105
Q

Which EKG waveform is used as a trigger for ESWL shocks?

A

R wave

106
Q

What are 4 contraindications for ESWL?

A

UTI, bleeding disorder or coagulopathy, distal urinary obstruction and pregnancy

107
Q

What level of neuraxial anesthetic block is required for ESWL?

A

T4-T6

108
Q

What are the hallmark clinical symptoms of TURP syndrome?

A

water intoxication, fluid overload, hyponatremia

109
Q

How much irrigation solution is absorbed by the body during prostate resection?

A

10-30mL/min of resection time

110
Q

What are complications of using mannitol for prostate irrigation?

A

pulmonary edema and hyponatremia

111
Q

What causes TURP blindness?

A

retinal dysfunction from glycine toxicity

112
Q

What position should be avoided in order to minimize risk of TURP syndrome>

A

Trendelenburg

113
Q

What is the maximum height of irrigation solution above the prostate to prevent TURP syndrome?

A

60cm

114
Q

Your patient is experiencing hyponatremia with TURP syndrome. Unfortunately your facility does not have 3% or 5% NS. What is your next option to correct the sodium?

A

9% sodium bicarbonate

115
Q

What position is the patient placed in for open nephrectomy?

A

lateral jackknife

116
Q

What is the functional unit of the liver?

A

hepatic lobule or acinus

117
Q

99% of bacteria entering the liver is removed by what type of cells?

A

Kupffer cells (macrophages)

118
Q

Which two vessels supply blood to the liver?

A

hepatic artery and portal vein

119
Q

The portal vein drains blood from which organs before entering the liver?

A

spleen, stomach, intestines, galbladder, pancreas

120
Q

What is the normal portal vein pressure? This pressure allows the liver to act as a circulatory reservoir.

A

6-10 mmHg

121
Q

What is the distribution of alpha and beta receptors in the arterial and portal circulations?

A

alpha and beta receptors in the arterial circulation. Only beta receptors in the portal circulation

122
Q

What three substances does the liver use for gluconeogenesis?

A

lactate, pyruvate, amino acids

123
Q

What are the three causes of hypoglycemia in patients with severe liver disease?

A

dysfunction of insulin clearance, decreased glycogen capacities, impaired gluconeogenesis

124
Q

How does a reduction in circulating plasma proteins affect starling forces?

A

decreased plasma oncotic pressure

125
Q

How does decreased plasma proteins affect volume of distribution?

A

increase Vd

126
Q

Heme is converted to what nephrotoxic substance?

A

unconjugated bilirubin

127
Q

What hormone is responsible for the release of bile from the gallbladder?

A

cholecystokinin (CCK)

128
Q

Bile secretion aids in the absorption of which vitamins?

A

fat-soluble: A, D, E, K

129
Q

What are two hematologic consequences of portal hypertension?

A

platelet sequestration and thrombocytopenia

130
Q

What occurs during phase 1 reactions?

A

Oxidation, reduction, hydrolysis

131
Q

What occurs during phase 2 reactions?

A

conjugation

132
Q

CYP450 enzymes are responsible for phase 1 or phase 2 reactions?

A

phase 1

133
Q

What is the most common reason for low albumin levels?

A

chronic liver disease caused by cirrhosis

134
Q

What are the two major presenting symptoms of halothane hepatitis?

A

Fever and then Jaundice

135
Q

How does hypercapnia and acidosis affect liver blood flow?

A

increase. Hypocapnia and alkalosis decrease hepatic blood flow.

136
Q

What is the most common cause of liver cancer and the most common reason for liver transplantation?

A

viral hepatitis

137
Q

Which forms of hepatitis are transmitted by contact with body fluids and physical contact with disrupted cutaneous barriers?

A

B, C and D

138
Q

What is the most critical determinant of drug-induced hepatitis?

A

genetic predisposition

139
Q

What forms of hepatitis infections can progress to chronic hepatitis?

A

Hepatitis B and C. Progression further to cirrhosis is rare

140
Q

Which lab value of coagulation is prolonged in patients with chronic hepatitis?

A

PT

141
Q

What lab values are used in the calculation of the MELD score?

A

bilirubin, creatinine, and INR

142
Q

What is the most common complication of cirrhosis?

A

ascites

143
Q

What are signs of hepatorenal syndrome?

A

progressive ascites, azotemia, oliguria and multisystem organ filure

144
Q

What is the triad of hepatopulmonary syndrome?

A

liver disease, arterial deoxygenation, widespread pulmonary vasodilation

145
Q

Ammonium is formed in the GI tract from what products?

A

degradation of amines, amino acids, purines, and urea

146
Q

What medications should be avoided in the patient with hepatic encephalopathy?

A

benzos and other sedatives

147
Q

What are manifestations of cirrhotic cardiomyopathy?

A

hyper dynamic circulation, elevated CO, reduced peripheral vascular resistance, decreased ventricular response to stressors

148
Q

Which biliary duct joins the gallbladder to the common bile duct?

A

cystic duct

149
Q

Which biliary duct begins at the junction of the cystic duct and the common hepatic duct?

A

common bile duct

150
Q

Gallbladder contraction is mediated by which hormone?

A

cholecystokinin (CCK)

151
Q

Obstruction by the cystic duct by gallstones causes what triad of symptoms?

A

sudden right upper quadrant pain, fever, leukocytosis

152
Q

How does an intraabdominal pressure of 20-25 affect CO and CVP? How about a pressure of 30-40 cm H2O?

A

20-25 increases CO and CVP. 30-40 decreases CO and CVP

153
Q

What type of organs secrete hormone products directly into the surrounding extracellular fluid?

A

endocrine glands

154
Q

Transmission of hormonal signals through the bloodstream to distant sites is called what?

A

endocrine function.

155
Q

Transmission of hormonal signals that act on neighboring cells is called what?

A

paracrine function

156
Q

If the secreted hormone act on the producer cell itself, the interaction is called what?

A

autocrine function

157
Q

What are the three categories of hormones?

A

proteins or peptides, tyrosine amino acid derivatives, and steroids

158
Q

Thyroid hormons, and catecholamine hormones are synthesized from which amino acid?

A

tyrosine

159
Q

Which two hormone categories has the longer circulating half life? (catecholamines, thyroid, peptide, steroid)

A

steroid and thyroid - due to plasma protein binding

160
Q

What is the half life of insulin?

A

7 minutes

161
Q

What structure holds the pituitary gland?

A

Sella turcica

162
Q

Which anterior pituitary hormone inhibits the synthesis and secretion of LH and FSH?

A

Prolactin

163
Q

Hypersecreating pituitary hormones are most likely to secrete which hormones?

A

Prolactin, ACTH, or GH

164
Q

what type of pathway does the anterior pituitary use to communicate with with hypothalamus?

A

vascular

165
Q

what type of pathway does the posterior pituitary use to communicate with the hypothalamus?

A

neural pathway

166
Q

ADH is synthesized from which nucleus of the hypothalamus?

A

supraoptic nucleus

167
Q

oxytocin is synthesized from which nuclei of the hypothalamus?

A

paraventricular

168
Q

What are the different actions of the vasopressin receptors? V1, V2, V3

A

V1 stimulates vasoconstriction. V2 stimulates water reabsorption. V3 stimulates corticotropin secretion.

169
Q

Where does ADH work?

A

V2 receptors of the collecting duct

170
Q

What is the primary stimulus for ADH secretion?

A

plasma osmolality

171
Q

What is renal tubular resistance to vasopressin called?

A

nephrogenic diabetes insipidus

172
Q

What are treatment options for DI?

A

DDAVP, sodium restriction, chloropropramide, carbamazepine, and thiazide diuretics

173
Q

What post-op complication is a potent stimulus for ADH secretion?

A

nausea

174
Q

What hormone controls calcium and phosphate metabolism?

A

PTH

175
Q

What electrolyte abnormality inhibits parathyroid gland function and PTH secretion?

A

chronic hypomagnesium or acute hypermagnesmia

176
Q

What hormone is secreted in response to increased calcium levels?

A

calcitonin

177
Q

Pregnancy and lactation predispose women to which derangement of parathyroid hormone?

A

hyperparathyroid

178
Q

How does alkalosis affect serum calcium levels? Acidosis?

A

shifts ionized calcium to the protein bound form and decreases serum calcium. Opposite is true for acidosis.

179
Q

What type of cells synthesize GI enzymes and bicarbonate into the pancreatic ducts to aid in digestion?

A

acinar cells

180
Q

What are the four cell types found in the islet of langerhans? What do they secrete?

A

Alpha- glucagon. Beta- insulin. Delta- somatostatin. PP- pancreatic polypeptide

181
Q

Cerebral function requires how many grams of glucose per day?

A

125-150g/day.

182
Q

What is the most important regulator of insulin release?

A

plasma glucose

183
Q

What hormones from the GI tract help lower blood glucose by potentiating insulin and decreasing glucagon secretion?

A

GIP and GLP-1

184
Q

What are the 4 diagnostic criteria for DM?

A

A1C > 6.5, fasting BG > 126, random BG > 200, 2 hour plasma BG >200

185
Q

What are the three factors increasing the incidence of DM?

A

overweight, sedentary lifestyles, aging population

186
Q

At what plasma glucose level does glucose spill into the urine?

A

180-200mg/dL

187
Q

What is the target blood glucose range in the perioperative period?

A

140-180

188
Q

What is the triad of DKA?

A

hyperglycemia, ketonemia, and acidosis

189
Q

What are the two most important controllers of aldosterone secretion?

A

serum potassium and angiotensin 2

190
Q

Where are the target cells for aldosterone located?

A

principal cells of the DCT and collecting duct

191
Q

How are the hypertensive effects of Conns syndrome treated?

A

spironolactone

192
Q

What is the most appropriate steroid replacement in the OR for the patient with acute adrenal crisis?

A

100mg hydrocortisone

193
Q

What is the largest paraganglion?

A

Organ of Zuckerandl.

194
Q

Which enzyme converts epinephrine to metanephrine and norepinephrine to normetanephrine?

A

COMT

195
Q

Do pheochromocytoma typically secrete more NE or Epi?

A

NE, alpha-adrenergic symptoms

196
Q

What is the most common symptom of a pheochromocytoma?

A

HTN

197
Q

What is the most common symptom of a pheochromocytoma?

A

HTN

198
Q

What is the preferred preoperative a-adrenergic blockers for a Pheochromocytoma?

A

phenoxybenzamine

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