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Neo Pathophys 2 > Renal > Flashcards

Renal Flashcards

1
Q

What does AKI stand for?

A

Acute Kidney Injury (FYI: used to be called acute renal failure)

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2
Q

When does urine begin to be excreted in the fetus?

A

9th wk gestation

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3
Q

What is the major component of Amniotic Fluid after 16-20 wks gestation?

A

Urine

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4
Q

When is Nephrogenesis complete?

A

32-36 wks, most literature says 34 wks at earliest.

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5
Q

Is post-natal Nephrogenesis accelerated after pre-term birth (like the skin)?

A

No. It develops at same rate as if still in-utero and may be Abnormal.

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6
Q

T/F Preterm babies develop all the Nephrons they would have made had they stayed in Utero.

A

False. They do not get all the Nephrons they would have if term.

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7
Q

Preemies are a set up for?

A

Chronic Kidney Disease

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8
Q

T/F, many preemies who have kidney problems will develop end stage renal failure later in life.

A

True

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9
Q

The term kidney has ______ nephrons

A

~ 1 Million (range 300k-1.8 M)

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10
Q

Name the 2 Parts of the Nephron

A
  1. Glomerulus

2. Renal tubule

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11
Q

Name the 2 Types of Nephron

A
  1. Cortical Nephron-glomerulus and tubular system in outer Cortex
  2. Juxtaglomerular Nephron-tubular system of the Nephron penetrates into Medulla
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12
Q

T/F 1 Collecting Tubule drains to a Collecting Duct

A

False. Many Collecting tubules go to a single Collecting Duct

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13
Q

Define Pelviectasis/Pyelectasis

A

Dilation of the Renal Pelvis

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14
Q

Is Pelviectasis/Pyelectasis common?

A

Yes, fairly common

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15
Q

What is Mild Renal Pelviectasis?

A

4-10 mm-mild dilation in 2nd Trimester

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16
Q

Does Mild Renal Peviectasis resolve?

A

Yes,97% resolve. Is probably just a stage in development.

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17
Q

Define Hydronephrosis.

A

Dilitation >10 mm on US

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18
Q

How common is Hydronephrosis, does it resolve, need F/U?

A

1-4% pregnancies, more male
Many prenatally dx will self-resolve
Needs F/U, obstruction may be cause

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19
Q

What are the 3 main functions of the Renal system?

A
  1. Eliminate Nitrogenous waste
  2. Control Composition of blood (electrolyte and acid/base balance)
  3. Endocrine Function (Erythropoetin, Calcitriol, Renin)
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20
Q

Erythropoetin is secreted in response to? What does Erythropoetin do?

A

Hypoxia. It is secreted from the kidney cells.

It stimulates the Bone Marrow to make RBC’s.

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21
Q

What is the function of Calcitriol?

A

It is the active form of Vit D. Works with Parathyroid H. to maintain Ca++ balance and make bones.

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22
Q

What is Renin responsible for?

A

Keeping the b/p up.

It controls the volume of blood (b/p).

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23
Q

In the Glomerulus, there are Afferent Arterioles and Efferent Artioles. Which is wider?

A

Afferent Arteriole

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24
Q

Describe what determines how much Hydrostatic Pressure is in the Bowman’s Capsule.

A

It is dependent on how dilated the Afferent Arteriole is and how constricted the Efferent Arteriole is.

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25
Q

Each Glomerular tuft has about how many capillaries in each?

A

about 50

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26
Q

Due to the Hydrostatic pressure in the Glomerulus, what happens?

A

H2O and small solutes are filtered out and enter the proximal convoluted tubule.

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27
Q

Can RBC’s filter through the proximal convoluted tubule?

A

No, usually too big to pass through the small slit-like pores in the glomerulus–They circle around and go back out through the Efferent Arteriole, back to circulation.

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28
Q

What does GFR stand for and what does it tell you?

A

Glomerular Filtration Rate.

Tells you how well the kidney is functioning.

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29
Q

What is the Definition of GFR?

A

The amount of filtrate that flows out of all Renal Nephrons of both Kidneys in 1 Minute.

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30
Q

At Term the GFR is ____% of Adults.

Preterm at 28 wks is ____% of Term.

A

50%

50%

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31
Q

About how long does it take a Term baby to double GFR?
How long does it take a preemie to double GFR?
What is it determined by?
When does it reach Adult values?

A

~ 2 Wks
As long as 6 wks for Preemie
Determined by Renal Vascular Resistance (RVR)
Reaches adult values by 2 yrs

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32
Q

The Tubular system selectively reabsorbs or secretes various substances in different portions by what mechanisms?

A

Active and Passive transport

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33
Q

Which tubule is the “work horse” reabsorbing most everything..the Proximal Convoluted Tubule or the Distal Convoluted Tubule?

A

The Proximal Convoluted Tubule

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34
Q

In addition to absorption and secretion, what are the other functions of the Proximal Convoluted Tubule?

A

pH balance:

  • H+ secretion/HCO3 reabsorption
  • Phosphate/Ammonia buffer systems (generate new HCO3)
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35
Q

What is the main anion Actively transported in the Loop of Henle?
Name the 4 other cations Passively transported with it.

A

Cl-

  1. Na+
  2. K+
  3. Ca++
  4. Mg+
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36
Q

Is H2O reabsorbed in the Loop of Henle?

A

No.

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37
Q

Name the 3 Hormones in the Distal Convoluted Tubule and Collecting Duct that fine tune Na+, K+, H+, Ca++, and H2O that haven’t been reabsorbed in the rest of the tubule.

A
  1. Aldosterone
  2. Antidiuretic Hormone (Argenine Vasopression-AVP)
  3. Parathyroid Hormone
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38
Q

What Hormone is assists with H2O reabsorption?

A

ADH (Anti-Diuretic Hormone/Argenine Vasopression AVP)

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39
Q

What do the cell so of the Macula Densa sense?

A

Osmolarity of filtrate

Osmoreceptors

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40
Q

What does the Macula Densa do if they sense high osmolarity of the Filtrate?

A

Signals the Juxtaglomerular Cells to secrete Renin (which exits the efferent arteriole to circuation)

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41
Q

Juxtaglomerular cells sense what?

A

Stretch

Baroreceptors

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42
Q

Where are most Juxtaglomerular cells located, the Afferent or Efferent Artirole?

A

Afferent Arteriole

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43
Q

What does Aldosterone do in the Distal Tubule?

What does it cause systemically and how?

A

It controls reabsorption of Na+
(2-5%, the last little bit)
Increased b/p because H2O follows Na+

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44
Q

What is secreted in exchange for the reabsorption of Na+ ions?

A

K+ & H+ ions are secreted in exchange for Na+.

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45
Q

A ____ amount of Na+ reabsorption in the distal tubule = _______ amount of Urine formation.

A

Small amount Na+ = Large amount Urine formed

you hold on to the urine, don’t excrete it

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46
Q

ADH tells the distal tubule what?

A

How much H2O it is going to retain.

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47
Q

ADH is produced where?
It is stored where?
It acts on the ____ _____ and ________ ___ to _________reabsorption of H2O

A

Hypothalamus
Anterior Pituitary
Distal Tubule and Collecting Duct to Increase

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48
Q

ADH allows for excretion of what type of urine?

A

Concentrated

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49
Q

Preemies are __________ to ADH.

A

Hypo-responsive to ADH

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50
Q

What syndrome is A/W excessive ADH secretion?

What types of babies are affected by this?

A

SIADH (Too much H2O retained)

MAS, Asphyxia, IVH, RDS, Pneumothorax

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51
Q

Parathyroid Hormone are responsible for reabsorbing?

What 2 locations does it act?

A

Ca++

Intestine and Distal Tubule

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52
Q

If PTH is present in the Distal Tubule, what happens to Ca+?

A

Ca+ is absorbed

if no PTH, No Ca+ absorption

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53
Q

A Renal insult between 32-35 wks effects what?

A

The final number of Nephrons.

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54
Q

What happens in the Glomerulus of a Preemie?

A
  • Immature Autoregulation of Afferent Arteriolar Dilation & Efferent Artiolar Constriction.
  • Underdeveloped and Hyporesponsive Receptor sites on the arterioles.
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55
Q

The Tubules have ______to increase absorption (like the intestines)

A

Microvilli

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56
Q

In a preemie, drug clearance is increased or delayed?

A

Delayed

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57
Q

Preemies have a shorter/longer underdeveloped Loop of Henle?

A

Shorter, underdeveloped loop

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58
Q

Preemies have hyporesponsiveness to Aldosterone in the distal collecting tubule causing what?

A

Loss Na+
Retention K+
Retention H+

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59
Q

Preemies have low/high circulating levels of ADH? Hyper/Hyporesponsiveness to ADH?

A

Low levels

Hyporesponsiveness (limited urine concentrating ability)

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60
Q

What is the HCO3 reabsorption threshold of a term baby?
Of a Preemie?
Micropreemie?

A

Term: 21 mEq/L
Preemie: 18 mEq/L
Micropreemie: 14 mEq/L

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61
Q

How do you Tx Metabolic Acidosis in Preemie d/t renal immaturity?

A
  • Use 1/2 Na Acetate instead of 1/2 NS in Arterial infusions
  • Omit Cysteine from TPN until pH normal (is essential but added as Cl-)
  • Add Na+ and K+ to TPN as Acetate
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62
Q

In an infant with respiratory issues, keeping a preterm infant slightly Alkalotic will keep pH normal while allowing for what?

A

Permissive Hypercapnia (compensating for resp. acidosis)

63
Q

Preemies are in a Negative or Positive Na+ and H2O balance the 1st few days?

A

Negative (normal adaptation)

64
Q

True/False: Preterm and Term babies have a limited ability to excrete a Large Na+ or H2O load?

A

True

65
Q

A “wet baby” is a ____ baby. It is A/W?

A

Bad. Keep them dry.

Severe RSV, CLD, Pulmonary Edema, CHF, PDA, IVH, NEC

66
Q

What range should you target Na+ in the transitional period?

When should you add Na+ to the IVF?

A

140-145 mEq/L

Not for first 24-72 hrs or until Serum level is <140 mEq/L

67
Q

What 2 things can cause Hyponatremia?

A
  1. Excessive fluid intake

2. Inadequate supplementation

68
Q

What 2 things can cause Hypernatremia?

A
  1. Inadequate fluid intake

2. Insensible water loss

69
Q

What is the avearage daily intake Na+ (per kg)

A

2-4 mEq/Kg/day

70
Q

Where do you want the serum Na if baby is on Diuretics?

A

130-135 mEq/L

71
Q

NS is = to _____mEq/L

A

0.154 mEq/L

72
Q

What 2 electrolytes are essential for optimal growth?

A

Na+ & K+

73
Q

Avoid adding K+ to TPN until what 2 things happen?

A
  1. Serum K+ starts to fall AND

2. UOP is WELL established

74
Q

Prerenal AKI is due to ?

A

Hypoperfusion of the Kidney

75
Q

Is Prerenal AKI reversible?

A

Yes, if Dx’d and Tx’d early

the kidney is intrinsically normal

76
Q

What can cause Prerenal AKI?

A

Maternal meds: ACE inhibitors, NSAIDS, Cyclooxygenase inhibitors (celebrex)
Antepartum hemorrhage
Birth Asphyxia
Hypothermia (decrease by 2 deg C can cause severe decrease GFR)
PostPartum Hemorrhage (IVH, Adrenal Hemorrhage, Subgaleal Hemorrhage)
Hypovolemia
Cardiac
Hypoxia
Obstruction of Venous Return
Septic Shock
Metabolic problems
Polycythemia
ECMO
Surgery w/cardiopulm. bypass
Meds that decrease blood flow (Indocin, Ace, Pheylepherine eye drops)

77
Q

What is Post Renal AKI?

A

Damage due to Mechanical Obstruction of Urine Flow somewhere in the Urinary System

78
Q

What is the most common cause of Post-Renal AKI in Males?

A

Posterior Urethral Valves (happens 4th wks gestation-d/t caudal end Wolfian Duct abnormal anastamoses).
10-15% need kidney transplant

79
Q

Besides posterior urethral valves, what are some other causes of Post-Renal AKI?

A 
Ureteropelvic Obstruction
Ureterovesical junction Obstruction
Urogenic Bladder
Urethral strictures/Obstructed catheter
Teratoma
Calculi
Renal Candidiasis (Fungal balls)
80
Q

What does AKI stand for?

A

Acute Kidney Injury

81
Q

Describe AKI

A

Intrinsic Renal Failure
~30% all NICU admits
EVERY Infant admitted to NICU is AT RISK

82
Q

Any prolongation of Prerenal or Postrenal failure will lead to_____ ______ to the kidneys.

A

Structural Damage

83
Q

What is usually the 1st presenting sign of AKI?

A

Low U.O.

84
Q

All infants void w/in ____ hrs.
Normal U.O. is __mL/kg/hr
Oliguria = __ mL/kr/hr

A

24
2-4 mL/kg/hr
<1 mL/kg/hr

85
Q

Abdominal masses are most likely to be?

A

Renal

86
Q

If an infant has a AKI, what other systems should be closely observed?

A

GU/Genital/ears

87
Q

You should get a Renal US with what type of cord?

A

2-vessel cord

88
Q

Congenital causes for renal/urinary system anomalies:

A

Renal Agenesis
Polycystic Kidney Dz
Congenital Nephrotic Syndrome
Renal Hypoplasia/Dsyplasia

89
Q

Besides congenital, what are the other reasons for AKI?

A 
Renal Vein Thrombosis (IDM w/hyperviscosity/polycythemia)
Renal Artery Thrombosis (have cold legs)
UAC 
Sepsis
DIC (microthrombi in glomerulus)
Nephrotoxins
90
Q

What is the underlying pathway of AKI regardless of cause?

A

Decreased GFR

91
Q

If baby is on Abx, and Creatinine is increased, what should you do with the Abx?

A

Space doses out (Decrease frequency). Give same dose (do not decrease dose).

92
Q

What would you see on UA as evidence of Tubular Damage?

A

Casts, Tubular cells, Protein (trace-2+ is o.k. in preemie)

93
Q

U. Cath taped to thigh of male infant may cause?

Where is it best to tape it?

A

Damage to Posterior Urethra

Tape it to the lower abdomen

94
Q

How often can a diagnostic fluid challenge/lasix be performed?

A

1-2 x’s max

95
Q

What does a fluid challenge r/o?

How is it performed?

A

Hypovolemia (pre-renal failure–would have Increased U.O. if pre-renal failure +)

10-20 mL/kg NS over 1-2 hrs + Lasix 1-1.5 mg/kg/dose IV

96
Q

Is there evidence for low dose Dopamine for renal perfusion?

A

No

97
Q

Hydrocortisone is for…?

A

Refractory Systemic hypotension in preterms with Adrenal insufficiency. (send cortisol level)

98
Q

Is BUN a specific marker for AKI?

A

No

99
Q

Is Creatinine a specific marker of AKI?
What does early level represent?
When may you see a rise in Crt?

A

Yes
Maternal Creatnine
After 25-50% of renal function is lost

100
Q

If Creatinine doubles ____% of renal function has been lost

A

50%

101
Q

Using lowest baseline Serum Crt what 3 items may indicate AKI?

A

SCr rise > 0.3mg/dL w/in 48 hrs
SCr rise >1.5 - 1.9 times baseline w/in 7 days
UOP >0.5 - <1 mL/kg/hr

102
Q

Fractional excretion of Na+ (in urine) may be used to Dx ____.
What must be complete for it to be accurate?

A

AKI–differentiates between prerenal and intrinsic renal failure >32-34 wks
Nephrogenesis

103
Q

Fractional Excretion of Na+ is not useful if…?

A

Lasix has been given

104
Q

With AKI, hyponatremia is due to what?

The hyponatremia is then what?

A 
Decreased UOP and fluid retention
Dilutional hyponatremia (too much free water)
105
Q

With AKI, how do you tx?

A

Cut fluids to insensible H2O loss + UOP (bare bones)

106
Q

What is term insensible H2O loss?

Preterm?

A 
~30-50 mL/kg/day
~30-65 mL/kg/day 1000-1250gm
 60-70 mL/kg/day 750-1000gm
 100-150 mL/kg/day <750 gm
(decrease amt if on vent or increased humidity)
107
Q

Is hyponatremia due to high output renal failure a good sign?

A

Yes. Possibly d/t glomerulus recovery but tubule hasn’t caught up yet.

108
Q

What happens in Hyponatremia d/t high out put renal failure.
How long do you see this?

A

BUN and Crt begin to decrease

Lasts 24-28hrs

109
Q

In Hyponatremia, when would you give Na+?

What dose?

A

120 mEq/L AND good UOP

10 mL/kg NS over 30-60 min

110
Q

How do you tx Na < 120mEq/L ?

What might this Na level result in?

A

“hot salts” 3% Na+, osmolarity 1.025mOsm/L–give 1-3mL IV over 15 min
May result in seizures–seizures usually stop after increase of 3-5 mEq/L in serum

111
Q

If Na is >120 mEq/L, and not seizing, best to correct Na over what time frame?
How?
What is the max increase of serum Na+ mEq/L in 24 hrs?
Why?

A

Correct slowly over 24-48 hrs
Add Na+ 1-3mEq/kg to IVF
No more than 8mEq/L in 24 hrs—Can cause dangerous fluid shift in brain

112
Q

What is the Na+ replacement formula?

A

Wt (kg) x 0.6 x (CD-CA) = dose (Na mEq)

Give 1/2 this amount over 12-24 hrs

113
Q

With AKI, may also see hyperkalemia. What is the serum level?
What clinical changes might you see?

A

6.5-7mEq/L
-EKG changes:
peaked T-waves
Flat P waves–>prolonged PR int–>eventual absent P waves
Wide QRS
Sine wave pattern
V. Fib/Asystole

114
Q

How would you tx Hyperkalemia?

A

Remove all K+ from infusions
Give 10% Ca Gluconate (heart protective-only if EKG changes other than just peaked T’s) Dose: 100-200mg/kg/dose over 10-30 min NOT in UAC
Continual Cardiac Monitoring

115
Q

What 3 things could you do to “hide” K+ from baby’s serum?

Why?

A
  1. 1/2 strength NaHCO3 (1-2mEq/kg 10-30 min)–flush line before & after w/Ca+ infusion
  2. Albuterol Neb
  3. Insulin/Glucose
    - -All 3 drive K+ into the cells temporarily
116
Q

How can you Rid the body of K+?

A

Lasix 1mg/kg IV Q 12 hrs
Cation exchange resins (kayexelate Rectally or OG/NG) ***exchanges K+ for Na+.
Binds K+ and is excreted in stool.

117
Q

When would you not want to use Kayexelate?

A

<29 wks
GI problems
Poor GI perfusion

118
Q

what is the ionized hypocalcemia level?

A

<4 mg/dL-term and preterm

119
Q

How do you treat acute Hypocalcemia?

A

Calcium Gluconate 100-200 mg/kg PIV/10-30 min w/Cardiac monitoring.
*If heart failure-use CaCl (doesn’t have to be metabolized 1st–but is 3x more caustic to veins)

120
Q

The kidney is the primary route of _____ elimination.

A

Phosphorous

121
Q

What does Phosphorus bind with?

How do you tx hyperphosphatemia with AKI?

A

Phos binds w/Ca++
Dietary Ca++ to bind PO4 (Calicum carbonate)
Phosphate binders (Aluminum hydroxide) “Amphagel”

122
Q

What is the normal Phosphorus range for Term? Preterm?

A
  1. 2-7mg/dL

4. 2-8.5mg/dL

123
Q

W/AKI keep pH between?

Why

A

7.2-7.25

Tx of acidosis increases Ca++ binding to Albumin–>decreased circulating iCa

124
Q

Which as better prognosis, Non-Oliguric AKI or Oliguric AKI?

A

Non-Oliguric AKI

125
Q

The Prognosis is AKI depends on ?

A

The Primary Cause

126
Q

What 4 factors do not influence prognosis of AKI

A
  1. Birth Wt
  2. APGAR score
  3. FeNa
  4. Peak Creatinine and BUN
127
Q

What type of diet would an infant in Chronic Renal Failure need?

A

High protein 3-4 g/kg/day

High calorie 150-180 Kcal/kg/day

128
Q

Name the 2 forms of dialysis

A
  1. Peritoneal

2. Hemdialysis (have to be big–wt)

129
Q

With Kidney transplant, is an adult kidney or kid kidney best?
Why?

A

Adult

Increased blood flow, pressure, & volume

130
Q

It’s ok to use a catheterized urine sample for culture unless looking for what?

A

Fungus, especially in uncircumcized male

131
Q

Name 4 indications of UTI on UC

A
  1. Leukocyte esterase
  2. Nitrites (bacteria convert Nitrates to Nitrites)
  3. Casts (of WBC’s)
  4. Neutrophil gelatinase
132
Q

What is Sensitivity?

A

A test’s ability to correctly label those who have the condition (Positive–you have it, it shows in test)

133
Q

What is Specificity?

A

A test’s ability to correctly label those who do not have the condition (Negative)

134
Q

Is prophylactic Abx use for babies at risk for UTI’s controversial?

A

Yes.
would use Amp, Amox, Septra
*Circ is recommended in this case

135
Q

Vancomycin kills any organism _________ kills.

A

Ampicillin

136
Q

Which grades of Vesicoureteral Reflux will an infant outgrow by 5 y/o?

A

1-3

137
Q

Which grade of reflux will likely need kidney removal?

A

5

138
Q

The PO dose of Lasix is ___ times that of IV dose.
Why?
Are PO/IV effects the same?

A

2 x’s
It has less bioavailability
Yes, same effect

139
Q

What is the major site of action of Lasix?

A

Loop of Henle

140
Q

How does Lasix work?

A 
It blocks active Cl- reabsorption
-blocks passive Na+ reabsorption
-blocks passive K+ reabsorption
-blocks passive Ca++ reabsorption
Only a small amount are reabsorbed at distal tubule through hormones (and H2O via ADH)
Rest are: "wasted" out of the body
141
Q

Name the side effects of Lasix

A

Hyponatremia, Hypocalcemia, Hypokalemia, and Hypochloremia.

Also Nephrocalcinosis, Ototoxicity

142
Q

What does Hypochloremia do?

A

Causes metabolic Alkalosis (Cl has inverse relationship w/HCO3)

143
Q

How does the body try to compensate for hypochloremia?

A

The lungs retain CO2 by hypoventilating.

144
Q

If you are trying to correct hypochloremia r/t Lasix, Give ____ to replace. Not______. Why?

A 
Give KCl 
Not NaCl (sm. amt ok in <34 wks d/t Na+ losses from renal immaturity)
H2O follows Na, defeating the purpose of the Lasix-vicious cycle.
145
Q

The body will normalize ____ at the expense of _____.

A

Normalizes K+ at the expense of Na+.
As K+ leaves cells to maintain serum K+, Na+ moves into the cells (causing hyponatremia).
Once K+ is restored, Na+ will move back out of the cells.

146
Q

When giving diuretics, and treating hypochloremia and hyponatremia, what level do you want Cl-? Na+?

A

Cl- up to 95

Na+ 130-135mEq/L

147
Q

Is Lasix ototoxic?

A

Yes. Do not combine w/Gentamicin if possible.

148
Q

Renal calcifcations can occur in babies after what cumulative dose?
When do they resolve?

A

20mg/kg

Resolve 6-12 months after d/c Lasix

149
Q

What is the major site of action of Thiazides?

A

Distal tubule–not as effective as Lasix as only a small amount of Na+ is absorbed there.

150
Q

What electrolytes are lost with use of Thiazides? Why?

A

Na+, K+ (due to increased UO), Cl- (folllows Na+ & K+)

151
Q

Which electrolyte is spared when giving Thiazides vs. Lasix? Why?

A

Ca++. Thiazides stimulate PTH secretion or potentiate it’s effects.

152
Q

Spironolactone’s major site of action is?

A

Distal tubule and collecting ducts.

153
Q

Spironolactone is ___sparing.
It inhibits what hormone?
Is the diuretic effect as good as Lasix?

A

K+.
Inhibits Aldosterone (thereby inhibiting Na+ reabsorption and inhibiting secretion of K+)—may not work in preemie who is hyporesponsive to Aldosterone
No.

154
Q

What is the equation for Fractional excretion of Na+?

A

Urine Na x Serum Cr / Urine Cr x Serum Na

U Na x S Cr / U Cr x S Na

Neo Pathophys 2 (20 decks)

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