Day 11 5/28/15

Question 1

Two Primary Functions of the Bladder

Answer 1

1. storage phase

2. emptying/voiding/micturition phase

Question 2

Parasympathetic Innervation of the Lower Urinary Tract

Answer 2

• innervate detrusor muscle; activation results in dtrusor muscle contaction and micturition
• S2-S4
• autonomic

Question 3

Sympathetic Innervation of the Lower Urinary Tract

Answer 3

-inhibits detrusor contraction and inc. tension in the smooth muscle of bladder neck and urethra, preventing micturition
-T10-L2
autonomic

Question 4

Motor Innervation of the Lower Urinary Tract

Answer 4

-bladder, pelvic floor, and urethral sphincter arise from segments S2-S4 of spinal cord

Question 5

Steps of Micturition Cycle

Answer 5

1) Increase in wall tension in the bladder
2) Afferent input overcomes the pontine micturition center
threshold and provides cortical egress micturition begins
3) Pudendal nerve activity ceases, the external sphincter/pelvic floor relaxes, detrusor neurons are freed and discharge
4) Proximal urethra opens
5) Bladder immediately contracts

Question 6

Types of Incontinence

Answer 6

• stress incontinence: involuntary, sudden loss of urine during inc. in intra-abdominal pressure (more common in women)
• urge incontinence: urgency, with or without incontinence, usually with frequency and nocturia (more common in men)

Question 7

Common Causes of Lower Urinary Tract Obstruction in Men

Answer 7

• benign prostatic hyperplasia
• urethral stricture
• cancer

Question 8

Indications for Starting Dialysis

Answer 8

• Dialysis is typically initiated when the risks of uremic complications exceed the risks of dialysis therapy
• Possible indications for dialysis include:
– Volume overload refractory to diuretics
– Hyperkalemia refractory to medical therapy
– Uremic pericarditis
– Uremic symptoms
– Other metabolic derangements (metabolic acidosis, severe hyperphosphatemia, calcium abnormalities)

Question 9

Modalities of Dialysis

Answer 9

• hemodialysis

- peritoneal dialysis

Question 10

Types of Vascular Access for Hemodialysis

Answer 10

• AV fistula (best)
• AV graft
• dialysis catheter

Question 11

Effect of HLA System in Human Kidney Transplantation

Answer 11

• Unless donor/recipient are HLA identical, recipient T cells will recognize foreign donor HLA antigens as “non-self” and mount a response (rejection).

Question 12

2 Types of Transplant Rejection

Answer 12

1)  Cellular (T-cell mediated)
•  T cells within tubular basement
membranes
•  Treatment: IV steroids, anti
thymocyte globulin (thymoglobulin)

2) Antibody (B-cell mediated)
•  Complement activation in peri-
tubular capillaries
•  Treatment: remove antibodies
(plasmapheresis), inhibit antibody production (IVIG, rituximab)

Question 13

Immunosuppressive Agents Used in Kidney Transplant

Answer 13

1. calcineurin inhibitor: cyclosporine, tacrolimus
   - nephrotoxicity, HTN, diabetes
2. proliferation inhibitor: MMP, sirolimus
   - cytopenias, GI toxicity
3. predisone
   - wieght gain, HTN, diabetes, hyperlipidemia, bone loss, cataracts

Question 14

Differential Dx of Transplant AKI

Answer 14

• prerenal: volume depletion, hypotension, renal artery thrombosis, CNI effects
• renal: delayed graft function, acute rejection, recurrent primary kidney disease, infection
• post renal: obstruction