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HA > Renal > Flashcards

Renal Flashcards

1
Q

Where do the kidneys sit

A

retroperitoneal between T12 and L3 (Right slightly more caudal to accommodate the liver).

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2
Q

primary functional unit of the kidney

A

nephron

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3
Q

Kidneys receive how much CO?

A

receive 20-25% of the cardiac output (1-1.25L)

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4
Q

Primary Functions of The Kidney

A

Maintenance of Extracellular volume and Composition (helps to concentrate and dilute)
Blood Pressure Regulation (Intermediate and Long term)
Excretion of toxins and metabolites
Maintenance of Acid-Base balance along w/ the lungs
Hormone Production
Blood glucose hemostasis

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5
Q

Hormones kidneys produce

A

erythropoietin (EPO),
calcitrol,
prostaglandins

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6
Q

What does low blood calcitrol cause

A

increases parathyroid hormone release, which increases the serum calcitriol level (active vit D) level. As serum calcium level rises it feeds back to reduce the serum level of PTH, which reduces the serum level of calictriol (negative feedback loop).

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7
Q

medications related to hormones that long term dialysis patients are on

A

iron and synthetic epo because dialysis negates the RBC’s

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8
Q

What is azotemia?

A

abnormally high levels ofnitrogen-containing compounds (such asurea,creatinine, various body waste compounds, and other nitrogen-rich compounds) in theblood. It is largely related to insufficient or dysfunctional filtering ofbloodby thekidneys.

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9
Q

What amount of body wt in non obese adult is total body water

A

60%

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10
Q

ICF vs ECF relationship

A

ECF is ½ the volume of ICF; kidneys effect ECF.

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11
Q

Two main components of ECF

A

plasma and interstitial fluid(IF)

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12
Q

Osmolality sensors in ant. hypothalmus
cause what?

A

Stimulate thirst
Vasopressin release; stop diuresis

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13
Q

sodium normal and cut-offs

A

normal 135 -145

cut-offs;
low; 125
high; 155

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14
Q

What percent of hospitalized patients have hyponatremia

A

15% …due to us giving IVF.

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15
Q

Causes of hyponatremia

A

Prolonged sweating- volume loss

Vomiting/diarrhea- GI disturbances

Insufficient aldosterone secretion- water overdose

Excessive intake of water; psych patients

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16
Q

Populations that we are concerned about hyponatremia with?

A

neuro and kids

forget about volumes-> too much fluid in kids

neuro- regulate swelling/ brain edema, limit na or water
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17
Q

Causes of AMS

A

BG, Drugs, electrolytes, stroke

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18
Q

s/s for 130-135 meq/L na

A

asytmomatic
ha
n/v
fatigue
confusion
muscle cramps
depression reflexes

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19
Q

s/s 120-130meq/L na

A

malaise
unsteadiness
ha
n/v
fatigue
confusion
muscle cramps

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20
Q

s/s na <120meq/L

A

ha
restlessness
lethargy
sz
brain-stem herniation
respiraory arrest
death

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21
Q

most severe consequences of hyponatremia

A

sz, coma, death

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22
Q

Hypertonic saline dose

A

1meq/L/hr

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23
Q

Hyponatremia tx

A

Underlying cause
Normal saline- resuscitative
Hypertonic saline
Lasix- concentrate fluid ( get rid of free water)
Mannitol
130-135 = gatorade

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24
Q

max correction rate for hypona

A

6 mEq/L in 24 hours

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25
Q

What does rapid correction of na cause

A

osmotic demyelination syndrome-> sz, coma, death

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26
Q

Close-to-death dose for 3%

A

About to die; 3-5ml/kg of 3% of 15-30 minutes till seizures/ symptoms resolve; killing brain cells if don’t correct quickly.

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27
Q

Hypernatremia causes

A

Excessive evaporation – no volume
Insufficient ADH
Poor oral intake…very young, very old
Overcorrection of hyponatremia
Excessive sodium bicarb/acidosis

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28
Q

what can we give with bicarb to buffer our acidosis correction?

A

THAM; trometamol

helps to avoid raising na w/ sodium bicarb

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29
Q

Effects of hypernatremia

A

Orthostasis- synopsize w/ standing
Restlessness
Lethargy
Tremor- spastic muscles
Muscle twitching/spasticity
Seizures
Death

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30
Q

Hypernatremia vital signs to check / assess volume status

A

vs; tachy and hypo, urine output, skin turgor, svv, cvp, ivc, labs, pap, tongue, us ICV.

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31
Q

treatment for hypernatremia

A

treatment based on the cause;

Hypovolemic: normal saline
Hypervolemic: diuretic
Euvolemic: water replacement (po or D5W)- free water

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32
Q

correction rate for hyperna

A

slower reduction rate of no more than 0.5 mmol/L per hour, with an absolute change of 10 mmol/L per day to avoid cerebral edema, seizure, and permanent neurologic damage from rapid correction

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33
Q

K+ normal and cut offs

A

normal; 3.5-5

cut-offs;
low; 3
high; 5.

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34
Q

How does DKA affect K+?

A

get acid out of the body by breathing and frequent urination of large volumes of urine -> hypokalemia

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35
Q

Hypokalemia causes

A

Excessive release of aldosterone
Diuretic drugs; should be taking K+ replacement
Kidney disease; our fault for over-dialysis?
Excessive intake of licorice
Diabetic ketoacidosis; diuresis out so much fluid.

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36
Q

At what level do we see arrhythmias with hypokalemia

A

2meq/L

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37
Q

Effects of hypokalemia

A

Dysrhythmias; U wave
Muscle weakness; treat w/ banana or lyte replacement
Cramps
Paralysis
Ileus – loss of peristalsis.
dig
chf ( chronic diuretic therapy)

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38
Q

IV dose for IV K replacement

A

Generally 10-20meq/hr IV.
10meq/ L/ Hr IV will increase hypokalemia by 0.1 or about by ~0.25 meq/L for each 20 meq K.

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39
Q

What does hydrocholothiazide cause

A

hypokalemia and increase in phos clearance, a decrease in tubular reabsorption of phosphate, and hypophosphatemia

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40
Q

When does phos correction occur

A

A decrease in phosphate clearance and a return of the plasma phosphate concentration to normal levels occurred after correction of the potassium deficit.

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41
Q

G tube color

A

stomach and clear

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42
Q

peritoneal dialysis tube color

A

white and smaller

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43
Q

Hyperkalemia causes

A

Renal disease- long term hd.
Insufficient secretion of aldosterone
Acidosis
Tissue/muscle damage
Use of depolarizing NMBD
Hypoventilation
blood products; large amount of free K
low flow states; tourniquet, arrest…

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44
Q

Why is sux contraindicated in hyperkalemia

A

increased K by 0.5meq.

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45
Q

Ph changes with potassium

A

pH 0.1 change causes 0.4-1.5 mEq/L shift

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46
Q

what does stored blood do to ca++

A

citrate lowers ca levels and loss of cell stability because of kelation of ca that we have available

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47
Q

Effects of hyperkalemia

A

Potentially asymptomatic…GI upset..malaise
Progresses to Skeletal muscle paralysis
Lowers resting membrane potential
Decreases action potential duration

Peaked T wave-> sine waves.

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48
Q

Treatment of hyperkalemia

A

Insulin 10 units to D50 25grams
Bicarbonate- secondary tx
fastest tx ; ca++ (stabilize cell membrane)
Dialyze day of surgery if possible
Increase respiratory rate
Albuterol; blow off K

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49
Q

Treatment of hyperkalemia

A

Insulin 10 units to D50 25grams
Bicarbonate- secondary tx
fastest tx ; ca++ (stabilize cell membrane)
Dialyze day of surgery if possible
Increase respiratory rate
Albuterol; blow off K

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50
Q

Glomerular filtration rate

A

Best measure for trend, not good for acute.
125-140 mL/min

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51
Q

Creatinine Clearance

A

Not reabsorbed
Most Reliable measure of GFR

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52
Q

Serum Creatinine normal values and what it does?

A

Estimate of GFR….75% below normal
0.6-1.0mg/dL - female
0.8-1.3 mg/dl- male

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53
Q

SERUM CREATININE produced

A

produced by skeletal muscle and is a byproduct of creatine breakdown.

Creatinine production is constant and directly proportional to muscle mass

Creatinine undergoes renal filtration but not reabsorption, making it a useful indicator of GFR.

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54
Q

increase in creatinine indication….

A

100% increase in creatinine indicates a 50% reduction in GFR. 1.2-> 2.4 = big drop in GFR.

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55
Q

Protein in urine

A

Large amounts of protein suggest glomerular injury (750mg/day or 3+ on dipstick) ….also seen in UTI’s

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56
Q

Blood urea nitrogen normal

A

Misleading…diet, intravascular volume
Normal 8-20mg/dL

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57
Q

Specific gravity normal and what its measuring

A

Compared to 1ml distilled water; 1 ml of ruine
Normal 1.001-1.035
more concentrated = more product retained

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58
Q

BUN:Creatinine ratio

A

generally 10:1

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59
Q

primary metabolite of protein metabolism

A

Urea is the primary metabolite of protein metabolism in the liver. (amino acids->ammonia->urea)

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60
Q

Urea undergoes…..

A

filtration and reabsorption, it’s a better indicator of uremic symptoms than as a measure of GFR.

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61
Q

BUN < 8 mg/dl causes

A

think dilution

overhydration
decrease urea production; malnutrition, severe liver diseases

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62
Q

BUN 20-40mg / dl causes

A

dehydration
taking in large amount of protein
GI bleeds
hematoma breakdown

catabolic state; trauma, sepsis,

decreased GFR

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63
Q

BUN > 50mg/ dl causes

A

decreased GFR

64
Q

BUN:Creatinine Ratio used for….

A

Since BUN undergoes filtration and reabsorption, but creatinine undergoes filtration but not reabsorption the ratio of these substances in the blood is helpful in evaluating fluid hydration status.

65
Q

Bun creat Ratio of >20:1

A

indicates prerenal azotemia

66
Q

causes of False urine sg

A

proteins
antibiotics
glucose
mannitol
diuretics
advanced age
radiographic contrast dye

67
Q

High specific gravity means…..

A

more concentrated=more solutes

68
Q

low SG means…

A

less concentrated=less solutes

69
Q

what does Specific gravity measure

A

Measures the ability of the kidney to concentrate or dilute urine

70
Q

Normal urine output

A

30ml/hr-No standardization for weight or clinical picture.

0.5-1ml/kg/hr may be more accurate

The normal values for total urine output range between800 to 2000 mLin adults with normal fluid intake of 2L during 24 hours. Normal urine output per hour values for adults need to be around1 mL/kg/hr.

71
Q

Early indicator of volume changes

A

base deficit
ph
lactate from volume loss

72
Q

Oliguria

A

500 mL in 24 h

73
Q

LAP is used for

A

wedge pressure

Powerful stimuli for renal vasoconstriction

74
Q

Stroke volume variance

A

have to be nsr and ventilated (postivie pressure)

Inspiratory vs expiratory pressure

use pulse ox or art line

75
Q

IVC Collapsibility

A

> 50% collapse indicates fluid deficit that will be responsive

Also consider passive leg raise to determine fluid responsiveness

Sub xyphoid , looking back toward the R flank toward the liver w/ curved probe

76
Q

echo for fluid status

A

is LV collapsed or dilated

77
Q

Acute renal failure deterioration

A

Hours-days
Large amounts of Nitrogenous waste products
Hard time Maintain fluid/electrolyte homeostasis

78
Q

AKI effects on mortality

A

AKI requiring dialysis and MSOF > 50% mortality
Sepsis
Cardiovascular dysfunction
Pulmonary complications

79
Q

Risk factors of AKI

A

Pre-existing renal disease
Advanced age
Congestive heart failure
PVD
Diabetes
Sepsis
Jaundice
Emergency surgery
Major operative procedures (X-Clamp)- femoral artery or aorta

80
Q

Acute renal failure dx

A

Serum creatinine rise > 0.5 mg/dL
50% decrease creatinine clearance
Serum creatinine change by 0.3 mg/dL within 48 hours

81
Q

Acute renal failure s/s

A

Malaise
Fluid overload
Hypotension

82
Q

Prerenal causes of ARF; bad before getting to kidney

A

not enough fluid
- sx; blood loss or npo for too long
- cardiogenic shock; not pumping too much
- sepsis vasodilated
- clot/ thromboembolism
- AAA/ clamping
-trauma,
- burns

83
Q

Renal azotemia cause

A

Acute glomerulonephritis
Vasculitis
Interstitial nephritis
ATN
Contrast dye
Nephrotoxic drugs (ABX)
Myoglobinuria (compartment syndrome)

84
Q

Postrenal Azotemia causes of ARF

A

Nephrolithiasis
BPH
Clot retention
Bladder carcinoma

85
Q

What makes up for 1/2 of hospitalized acquired cases of arf

A

Pre-renal azotemia

86
Q

Most common cause of ATN

A

Pre-renal azotemia if not reversed rapidly

87
Q

fractional excretion of prerenal oliguria

A

< 1

88
Q

fractional excretion of ATN

A

> 3

89
Q

urinary na prerenal oliguria

A

< 20

90
Q

Urinary Na ATN

A

> 20

91
Q

urine osmolarity prerenal oliguria

A

> 500

92
Q

Urine osmolarity for atn

A

< 400

93
Q

Bun; Creatinine ratio for prerenal oliguria

A

> 20; 1

94
Q

Bun; creatinine ratio for ATN

A

10-20; 1

95
Q

Sediment for prerenal oliguria

A

normal
possible hyaline casts

96
Q

sediment for atn

A

tubular epithelial cells
granular casts

97
Q

Reperfusion injury releases;

A

Cytokines
Oxygen-free radicals
Other inflammatory cells

98
Q

The BUN:Cr in renal azotemia

A

is less than 15

. Creatinine filtration decreases, leading to a higher amount of creatinine in the blood

99
Q

causes of postrenal AKI

A

Cellular debri; UTI / obstructed -> frank puss
Result of tumor and can’t void -> post renal failure.
Trauma to urinary -> traumatic insertion of foley
Bladder pressure and forgot to release the pressure -> post renal failure.
Most common cuase; Stones

100
Q

Neurological complications of AKI

A

Related to build up of protein and amino acids in blood-> Uremic Encephalopathy(also seen in chronic rf)
Don’t respond to conservative stuff, need emergent HD.
Improved with dialysis

101
Q

hemotologic complications in AKI

A

anemia
-Decreased red cell production
-Decreased red cell survival
-Decreased erythropoietin production
-Hemodilution
Plat dysfunction good number but dysfunction. Uremic bleeding. Plat function panel. Get teg or rotem
DDAVP (vasopressin)

102
Q

Anesthesia concerns for aki

A

Correct fluid, electrolyte, acid/base status
MAP maintained
Vasopressors- decrease perfusions = worsening things.
Prophylactic sodium bicarb- infusion 350 meq/ 3 amps in 1 L over 3-5 hr = decrease free radical

art line?
preop dialysis

103
Q

leading cause of ESRD

A

Diabetes mellitus
Hypertension

104
Q

Rifle criteria

A

risk
injuiry
failure
loss
ESRD

105
Q

RIFLE; risk

A

scr; increase in scr to > 1.5x baseline
uop < 0.5 ml/kg/hr for > 6hrs

106
Q

Rifle; Injury

A

scr; increase in scr to 2x baseline
uop < 0.5 ml/kg/hr for 12 hrs

107
Q

rifle; failure

A

increase in scr to 3x baseline or increase > 0.5 mg/dl to absolute value of > 4mg/dl

uop < 0.3 ml/kg > 12 hr or anuria for > 12 hr

108
Q

Rifle; loss

A

need for renal replacement therapy > 4 weeks

109
Q

Rifle; End- stage

A

need for renal replacement therapy > 3 months

110
Q

Stage 1 of ESRD

A

Kidney damage with normal or increased GFR
GFR > 90 mL/min/1.73m2

111
Q

Stage 2 of ESRD

A

Kidney damage with mildly decreased GFR
GFR 60-89

112
Q

Stage 3 of ESRD

A

Moderately decreased GFR
GFR; 30-59

113
Q

Stage 4 ESRD

A

Severely decreased GFR
GFR; 15-29

114
Q

Stage 5 ESRD

A

Kidney failure
GFR < 15

115
Q

GFR equation

A

186 x (SCr)-1.154x (age)-0.203x (0.742 if female) x (1.210 if African American)

116
Q

GFR relationship to age

A

GFR decreases by 10 points per decade starting from age 20.

117
Q

ACE’s and ARB’s effects

A

Decrease systemic and glomerular hypertension

Decrease proteinuria

Decrease glomerulosclerosis

118
Q

Taget hbg for CKD

A

Target Hbg 10

119
Q

indications for dialysis

A

volume overload,
hyperkalemia,
severe metabolic acidosis, symptomatic uremia,
medication overdose/ failure to clear meds.

120
Q

leading cause of death in dialysis patients

A

infection

121
Q

most common adverse event for dialysis patients

A

hypotension

122
Q

Fluids to avoid in renal pts

A

hydroxyethyl starches are clearly associated with increased risk of renal injury.
careful w/ albumin

123
Q

Vasopressin preferentially constricts the….

A

efferent arteriole. It maintains GFR and UOP better than norepi or neo

124
Q

Uremic bleeding w/ ESRD

A

Despite normal platelet count/functioning
Cryo…F VIII and vWF;takes time to work
Desmopressin….- give in preop
-Max effect 2-4 hours; lasts 6-8 hours
-Tachyphylaxis

125
Q

NMB that are not dependent on the kidneys

A

nimbex; eliminated w/ hoffman elimination/ plasmaesteraces that are affected by temperature

126
Q

Meds to avoid in ESRD

A

morphine and meperidine because it has active metabolites (normepderiine/ demerol)

neurotoxicity

127
Q

Med that are lipid insoluble

A

Thiazide diuretics
Loop diuretics
Digoxin
Many antibiotics

Eliminated unchanged in urine…duration of action prolonged

if not lipid solube = reduce the dosage

dose based on GFR

128
Q

Consideration of H2 R blockers in ESRD patients

A

All H2-receptor blockers are excreted renally; therefore dosage adjustment is required

129
Q

TURP

A

Transurethral resection of the prostate

problem; Intravascular volume changes

Neuraxial anesthesia is common, usually a spinal to t10 level

Electrolyte changes due to large volumes of irrigation fluids and can assess ams because they’re awake

The pressure of infusion is influenced by the height of the irrigation solution. Should be no more than 60cm above the patients and perhaps decreased over time. Case should be no longer than 1 hr but is frequently longer especially in robotic assisted cases.

130
Q

Estimated absportion volume of irrigation fluid for TURN procedure

A

Estimated absorption volume is 10-30ml/min-> TURP syndrome

131
Q

Cons of using NaCl for irrigation fluid

A

can only be used w/ bipolar electrocautery

don’t use unipolar
can transmit electrical current to the patient

132
Q

TURP Syndrome and na and tx

A

Sodium <120mEq/L increased risk of complications
Sodium <110mEq/L is associated with seizure, coma and arrhythmias

tx ; 3%, diuretics

133
Q

Nephrolithiasis

A

Renal Stone

134
Q

Urethrolithiasis

A

Ureter stone

135
Q

Cystolithiasis

A

Bladder stone

136
Q

Urolithiasis most common type of stones

A

contain calcium and are radio-opaque

137
Q

Urolithiasis tx

A

Conservative nonsurgical therapy for smaller stones consists of analgesics
NSAIDs and/or opiates
Aggressive fluid administration to promote urine flow and passage of the stone
Medical expulsive therapy (MET)
Promote ureter relaxation and the spontaneous passage of small ureteral stones

138
Q

ESWL

A

extracorporeal shock wave lithotripsy
Directed energy directed at the stone

139
Q

ESWL absolute contraindications

A

pregnancy
risk of bleeding

140
Q

ESWL relative contraindications

A

pacemaker/ ICD
Calcified aneurysm of the aorta or renal artery
UTI
obstruction beyond the renal stone
morbid obesity

141
Q

ESWL what to avoid?

A

The shock wave is timed to the R wave to reduce the risk of R on t phenomenon-May chemically increase the HR to accomplish the procedure
bradycardia; give glycopyrrolate to speed up heart and increase the procedure.

142
Q

PCNL

A

Percutaneous nephrolithotomy
Used after ESWL is unsuccessful
Place urethral stents then nephrostomy tube to access the stone
Usually done with GETA in the prone position
Irrigation is also used to TURP syndrome is possible
PTX may also occur during tube placement

143
Q

Laser Lithotripsy

A

Break up the stone with lasers
Concerns with the laser exposure
Irrigation is also used to TURP syndrome is possible
Usually done with patients in lithotomy

144
Q

Renal concerns with paraplegic pts

A

Paraplegic patients with sensory deficits below T6 are at risk for autonomic hyperreflexia and require anesthesia to block the afferent stimulation that can provoke this reaction (e.g., bladder distension)

145
Q

Medication that influences the renal arterial tone

A

angiotensin, ne, epi

146
Q

The primary source of Urea is….

A

liver

147
Q

normal creatinine clearance

A

110-150 ml/min

148
Q

creatinine clearance for mild renal impairment

A

40-60 ml/min

149
Q

creatinine clearance for moderate renal impairment

A

25-40 ml/min

150
Q

These drugs undergo hepatic metabolism and conjugation prior to elimination in urine

A

Pavulon
benzos
opioids

151
Q

The ideal VAA for renal pts

A

forane- isoflorane

152
Q

what are the three layers of the kidney

A

renal capsule
adipose capsule
renal fascia

153
Q

acceptable uop for pt in the or

A

0.5mg/kg/ hr unless pt is on bypass then it is 1 ml/kg/hr

154
Q

Renin is secreted by the?

A

JXA

155
Q

Each kidney contains how many nephrons

A

1-1.2 milllion nephrons

156
Q

why do they put in stents for gyn cases

A

reduce the risk of UTI

HA (15 decks)

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