Kidney Disease Flashcards
(94 cards)
1
Q
The hydrostatic pressure gradient forces
A
glomerular filtration.
2
Q
–% of renal plasma flow is filtered into Bowman’s capsule; – factors contribute
to the filtration rate
A
20
hemodynamic
3
Q
Glomerular Filtration Rate (GFR) affected by renal artery pressure
other autoregulation factors of GFR
(3)
A
- vasoreactive (myogenic) reflex of afferent arteriole
- tubuloglomerular feedback (TGF)
- angiotensin II-mediated vasoconstriction of the efferent arteriole
4
Q
- vasoreactive (myogenic) reflex of afferent arteriole
- causes
A
dilatation or constriction of the afferent arteriole to maintain
stable glomerular pressure in response to variations in systole
5
Q
- tubuloglomerular feedback (TGF)
- causes
A
dilatation or constriction of the afferent arteriole to maintain
stable glomerular pressure in response to solute concentration changes
detected by the macula densa cells in the distal/ascending Loop of
Henle
6
Q
Kidney Function
(9)
A
- Water regulation
- Electrolyte regulation
- Extracellular volume/pressure regulation
- Acid-base homeostasis
- Endocrine/metabolic
- Blood plasma filtration
- Excretion of metabolic waste
- Urine production
- Prostaglandin production
7
Q
Endocrine/metabolic
(5)
A
oKinins
oErythropoietin
oPhosphate
oVitamin D
oRenin
8
Q
Blood plasma filtration
(2)
A
oGlucose and amino acid reabsorption
oCalcium and phosphate regulation
9
Q
Excretion of metabolic waste
–, etc.
A
nitrogenous
10
Q
Acute Renal Failure (ARF)
aka
Acute Kidney Injury (AKI)
A condition in which the…
— results from the cumulative effects of renal failure, retention of excretory products,
and interference with metabolic and endocrine function
Acute renal failure develops… It may be fatal. It’s most
common in those who are…
A
kidneys suddenly can’t filter waste from the blood.
Uremia
rapidly over a few hours or days
critically ill and already hospitalized.
11
Q
Acute Kidney Injury (AKI)
Acute Renal Failure (ARF)
Symptoms
(6)
A
decreased urinary output
swelling due to fluid retention
nausea
Fatigue
shortness of breath.
Sometimes symptoms may be subtle or may not
appear at all.
12
Q
ARF
Causes
(3)
A
- Pre-renal
- Intrinsic Renal
- Post-renal
13
Q
ACE-I: (3)
A
monopril, captopril, enalapril
14
Q
ARB:
A
angiotensin receptor blocker, (Diovan, Cozaar,
Benicar);
15
Q
NSAIDs:
A
Indomethacin
16
Q
PPI: proton pump inhibitors (3)
A
Prilosec, Prevacid &
Nexium (also linked to stomach cancer)
17
Q
TTP-HUS, thrombotic thrombocytopenic purpura–
— syndrome.
A
hemolytic-uremic
18
Q
Acute Kidney Injury (AKI)
Acute Renal Failure (ARF)
Treatments
(4)
A
address the underlying cause
fluids
medication
dialysis.
19
Q
Chronic Kidney Disease
Causes
(6)
A
*Chronic Glomerulonephritis
*Systemic Lupus Erythematosus
*Neoplasms
*Polycystic kidney disease
*AIDS nephropathy
*Diabetic nephropathy
*Etc. (many others)
20
Q
Chronic Kidney Disease
Risk Factors
(5)
A
Age (≥60 years of age)
Smoking
Obesity
HTN
Diabetes
21
Q
HTN
A
- poorly controlled
22
Q
Diabetes
* —% of patients with type 2 DM will
develop CKD
A
40-50
23
Q
Chronic Kidney Disease
Risk Factors
(4)
A
Nephrotoxins/Drugs
Infections
Low birthweight
Chronic Inflammation
24
Q
Test: Glomerular Filtration Rate (GFR)
Chronic Kidney Disease
A
<60 ml/min/1. 73 m
25
Test:
Chronic Kidney Disease
Urinary albumin/creatinine ratio
≥ 30 mg/g
26
Test: Urinary albumin excretion rate
Chronic Kidney Disease
≥ 30 mg/day
27
Diagnosis and Classification of CKD are based on
GFR and albuminuria/proteinuria
28
End-Stage Renal Disease (ESRD)
(2)
* GFR <15 ml/min/1.73 m2
* Requires kidney replacement therapy (hemodialysis, transplantation)
29
* GFR steadily decreases with
age
30
CKD
Complications
I. Fluid and electrolyte imbalance
(3)
* Dysregulation of Na+, K+ and H2O reabsorption
* Hyperkalemia
* Edema
31
CKD
Complications
II. Hypertension
(3)
* RAS activation
* Aldosterone and catecholamine activation
* Hypervolemia
32
CKD
Complications
V. Anemia [Hb <12 g/dl (F); <13.5 g/dl (M)]
(3)
* Decreased Epo and RBC survival
* Impaired iron absorption (insufficient hepcidin),
blood loss (dialysis)
* Normocytic, normochromic anemia
33
CKD
Complications
VII. Dyslipidemia
(2)
* Dysregulated metabolism of lipid and uremic toxin-mediated
lipid alterations
* Atherosclerosis
34
CKD
Complications
VIII. Metabolic acidosis
(2)
* Decreased excretion of NH4+
* Decreased absorption of H+ and HCO3-
35
CKD
Complications
IX. Mineral bone disorder (MBD)
* Decreased --- levels
* Dysregulation of (2)
* Increased (2) levels
* Diseases (2)
* Calciphylaxis –
vitamin D
Ca2+ and PO4-3
PTH and FGF23
Renal Osteodystrophy, secondary hyperparathyroidism
extraosseous calcifications
➢Blood vessels of dermis & subcutaneous fat
36
CKD
Complications
others (3)
III. Cardiovascular Disease
IV. Endocrine dysfunction
VI. Hyperuricemia (uric acid) and Uremia (urea)
37
CKD
Diabetic Management
Control DM –HbA1
Control HTN –BP -- mm Hg
Control HLD –LDL <---mg/dl
Diet/lifestyle modification –BMI
<8%
<140/90
100
18.5 -24.9 kg/m2
38
Control HTN –BP <140/90 mm Hg
(5)
* Cardioselective beta-blocker
* Diuretics
* ACE inhibitor
* ARB
* Calcium channel blocker
39
Diabetic management
Management of other comorbidities
and complications
(5)
* Neuropathies
* Anemia
* Mineral bone disease
* Metabolic acidosis
* Hyperkalemia
40
CKD
Oral Manifestations
(7)
Xerostomia/dry mouth
Halitosis
Dysgeusia
Infections
Enamel defects
Uremic stomatitis (rare)
Petechiae and ecchymosis
41
Dysgeusia
* Metallic taste
42
Infections
(4)
* Opportunistic
* Periodontal
* Odontogenic
* Salivary
43
Enamel defects
(1)
* Children
44
Uremic stomatitis (rare)
(1)
* BUN >55 mg/dl
45
Osteodystrophy
* Lack of
* Causes lack of
* Stimulates (2)
* Inhibits
hydroxylation of 25(OH)D to 1,25(OH)2D which takes place in the kidneys
Ca+ absorption from intestines
parathormone secretion and Ca+ loss from bone
bone mineralization
46
Osteodystrophy Causes
(6)
* Loss of lamina dura
* Demineralization (“ground-glass”)
* Expansile radiolucencies (CGCG, brown tumor)
* Wide trabeculae
* Loss of cortication
* Sclerosis
47
Oral manifestations
Alternative filtering of the blood
removes uremic toxins; initiated in ESRD
48
Two modalities
Hemodialysis (venous access)
Peritoneal dialysis
49
Hemodialysis (venous access)
* Arteriovenous fistula
* Ateriovenous graft
* Central venous catheter (special, short-term)
* --- filters blood
* --- is typically used
* Every ---
* Risk of infectious disease – (2)
Machine
Heparin
2-3 days; 3-4 hours/session
Hep B; Hep C
50
Peritoneal dialysis
* --- solution in peritoneal cavity
* --- used for exchange
* ---x/day or ---
Hypertonic
Peritoneal membrane
3-5, overnight
51
Dental treatment planned for the
day -- hemodialysis
AFTER
52
Kidney Replacement Therapy
Organ Transplant
Requires Matching
(4)
* ABO matching
* HLA matching
* > 5- year life expectancy
* Can be from live (better) or deceased donor
53
* Can be from live (better) or deceased donor
oRelated mismatched donor (3/6 match) is better
than deceased donor
54
Organ Transplant
Absolute contraindications
(2)
* AIDS
* Active hepatitis
55
Organ Transplant
Rejection may be a problem
(3)
* Activated cytotoxic T cells (direct)
* Alloantibodies (direct)
* Delayed type hypersensitivity –arteriosclerosis of
transplant (indirect)
56
Kidney Replacement Therapy
Organ Transplant
Requires
immunosuppression
57
Kidney Replacement Therapy
Organ Transplant
Induction (prevent acute rejection)
(2)
* Antithymocuyte globulin
* Alemtuzumab (anti-CD52)
58
Kidney Replacement Therapy
Organ Transplant
Maintenance (unless identical twin)
(3)
* Azathioprine
* Mycophenolate mofetil
* Steroids
59
* Azathioprine
(2)
oAntimetabolite
oInhibits DNA and/or RNA synthesis
60
* Mycophenolate mofetil
(2)
oSimilar to azathioprine
oLess bone marrow suppression
61
* Steroids
(1)
oLow doses, adjunct
62
Kidney Replacement Therapy
Organ Transplant
Important adverse effects
(2)
* Cytopenias (bone marrow suppression)
* Increased risk of developing skin and
hematologic cancers
63
Cytopenias (bone marrow suppression)
➢ Bleeding
(1)
▪ Severe thrombocytopenia <50K
64
* Cytopenias (bone marrow suppression)
➢ Susceptibility to infection
▪ Severe leukopenia/neutropenia
oWBC <2000
oANC <500
65
Kidney Replacement Therapy
Organ Transplant
Maintenance (unless identical twin)
* Calcineurin inhibitors
(4)
oCyclosporine
oTacrolimus
oBoth decrease production of IL-2
mRNA and proinflammatory
cytokines
oDiabetes and nephrotoxicity
complications
66
Kidney Replacement Therapy
Organ Transplant
Maintenance (unless identical twin)
* mTOR inhibitors (mTORi)
(3)
oSirolimus
oEverolimus
oInhibits T cell proliferation signaling
67
Kidney Replacement Therapy
Organ Transplant
Maintenance (unless identical twin)
* Belatacept
(2)
* Binds costimulatory molecules
* T cell anergy and apoptosis
68
Kidney Replacement Therapy
Organ Transplant
Oral adverse effects
(2)
* Gingival hyperplasia (cyclosporine)
* Aphthous-like ulcers (mTORi)
69
Determine level of renal impairment and disease control
* BP –Avoid arm with AV shunt when measuring BP
* GFR
* BUN
* Creatinine clearance
* Serum creatinine
* Electrolytes
70
Level of Renal Impairment may affect bleeding –assess risk
* Patients can be at risk for both (2)
* Quantitative and qualitative
* --- measures as necessary
* Be aware of signs and symptoms of ---
* Referral to a specialized center as necessary
bleeding and thrombosis
platelet impairment
Hemostatic
thrombosis
71
* Quantitative and qualitative platelet impairment
(3)
➢ Platelet count
➢ PT-INR
➢ PTT
72
Advanced uremia →
decreased immune function
73
Assess Indication for Antibiotics
Treat infections ---
aggressively
74
If invasive procedures in patients with stage 4 (severe) or end-stage renal disease →
consult physician about need for antibiotics
75
Antibiotic prophylaxis IS NOT routinely necessary for
peritoneal dialysis
76
Antibiotic prophylaxis may be necessary for patients with a
synthetic AV graft
77
Antibiotic prophylaxis is necessary in hemodialysis patients if performing
incision and
drainage
78
Drug interactions/side effects –dose adjustment may be necessary
(4)
* Check drug excretion mechanism
* Caution with nephrotoxic drugs (acyclovir, NSAIDs, aspirin, aminoglycosides,
tetracycline)
* Carefully review possible drug interactions with current medication list when
prescribing new medications
* Consult with patient’s physician
79
Acetaminophen
(4)
* Nephrotoxic at high doses
* Increase dosing interval
oq6h (GFR >10 but <50ml/min)
oq8hs (GFR <10ml/mim)
80
NSAIDs - AVOID
* Except for --- for ---
* Especially ---
* Interaction with ---
* Impairment of --- production
➢ ---, reduced renal ---
aspirin, CVD
long-term use
antihypertensives
prostaglandin
Vasoconstriction, perfusion
81
Opioids - AVOID
* Risk for accumulation of ---
* ? with dose adjustment and/or increased dosing interval
* Consult with physician
toxic metabolites
Tramadol
82
Benzodiazepines - CAUTION
* Consider
* --- dosing, consult with physician
half-life, active metabolite
Single
83
Acyclovir
* Increase dosing interval q8h or q12h
84
Antibiotics
* No adjustment required
(4)
oClindamycin
oDoxycycline
oErythromycin
oMetronidazole
85
Antibiotics
* Adjustment required
(3)
oAmoxicillin –q12h or q24h
oCephalexin –q6-18h or q12-24 h
oAzithromycin –avoid if GFR <10
86
Fluconazole
* Reduce to 50% or 25% of
original dose
87
Nystatin –
No adjustment
88
Goals of pre-transplant dental clearance
Remove active foci of infection and limit potential foci of infection (think 6 months)
*Treat active foci of infection
(3)
oSRP
oEndodontic treatment
oRestorations
89
Goals of pre-transplant dental clearance
Remove active foci of infection and limit potential foci of infection (think 6 months)
(4)
*Treat active foci of infection
*Extract teeth with questionable (even if in your opinion minimally)/poor prognosis
*Assess caries risk and need for adjuncts (fluoride)
*Educate patient on importance of maintaining good homecare, diet and professional
maintenance
90
Take into account patient compliance and, unfortunately, patient --- when
planning treatment
economics
91
Defer elective treatment within first 6 months post-transplant
* Emergency care only –consider specialized center
92
If planned correctly pre-transplant and patient is compliant
Dental Maintenance
Surveillance
(3)
* Opportunistic infections (odontogenic, candidiasis, aspergillosis, HSV, OHL, CMV)
* Toxicities/side effects of systemic treatment
* Cancer
93
Toxicities/side effects of systemic treatment
oAdrenal insufficiency –
oGingival hyperplasia -
oPyogenic granuloma and OFG-like lesions -
oOral ulcerations –
long-term high-dose corticosteroids
cyclosporine
tacrolimus
sirolimus
94
Cancer
(3)
oNon-melanoma skin cancer (basal cell and squamous cell carcinoma [SCCa])
oPost-transplantation lymphoproliferative disorder (frequently EBV associated, B cell)
oOther solid cancers including oral SCCa
