Renal Disorders

Question 1

How are glucose and insulin used to treat hyperkalemia associated with AKI?

Answer 1

when insulin transports glucose into cells, it carries potassium with it

Question 2

Most common causes of CKD

Answer 2

Diabetes (35%)
High blood pressure (30%)
Glomerulonephritis (12%)

Question 3

Functions of the kidney

Answer 3

1. waste management
2. drug and peptide hormone elimination
3. maintenance of fluid and electrolyte balance
4. regulation of acid-base balance
5. endocrine functions
6. regulation of extracellular fluid balance and BP

Question 4

Hormones associated with kidneys

Answer 4

a. Renin - RAAS
b. Aldosterone - reabsorption at distal tubule
c. ADH - reabsorption at collecting tubule
d. activate vitamin D - stimulate Ca and phosphate absorption in intestine
e. erythropoietin formation - bone marrow

Question 5

What goes on in the Glomerulus/Bowman’s Capsule

Answer 5

Filtration

• water, NaCl, glucose, amino acids, urea

Question 6

What goes on in proximal convoluted tubule?

Answer 6

Reabsorption

• NaCl, water, urea, bicarbonate, glucose, others

Question 7

What goes on in Loop of Henle?

Answer 7

Concentrate urin

reabsorb water (descending loop)
reabsorb sodium (ascending loop)
urea secretion (thin segment)

Question 8

What goes on in distal convoluted tubule and collecting tubule?

Answer 8

distal tubule: acid-base balance

collecting tubule: electrolyte/fluid balance

Question 9

How much fluid does the kidney filter per day?

Answer 9

180L/day

120mL/min

Question 10

Causes of Pre-renal AKI

Answer 10

reduction in blood flow to kidney

a. hypovolemia
b. decreased CO
c. thrombo-embolic obstruction of renal vasculature

Question 11

Causes of intra-renal AKI

Answer 11

damage to structures within kidney

a. acute tubular necrosis
b. glomerular, tubular or interstitial damage

Question 12

Causes of post-renal AKI

Answer 12

obstruction in the urinary tract BELOW kidney

a. renal calculi (kidney stones)
b. clots in ureters/urethra
c. tumours

Question 13

Kidneys receive how many percent of CO?

Answer 13

20-25%

Question 14

Acute Tubular Necrosis (ATN)

Answer 14

death of tubular epithelial cells, damage to tubules

caused by nephrotoxic drugs, severe hemolytic reactions or muscle trauma

Question 15

Glomerulonephritis

Answer 15

inflammation of the glomeruli caused by an IMMUNE RESPONSE

antigen-antibody complex trapped in glomerulus, causing large molecules to enter filtrate

Question 16

Manifestations of glomerulonephritis

Answer 16

hematuria
proteinuria
hypertension
edema

Question 17

Pyelonephritis

Answer 17

inflammation of kidney pelvis and parenchyma from infection

• can descend from bloodstream or ascend from UTI
• causing fibrosis formation

Question 18

Manifestations of pyelonephritis

Answer 18

Fever
abdo pain
dysuria (pain when urinating)
cloudy urine
polyuria/urgency
urinary odour

Question 19

Nephrotic syndrome

Answer 19

urinary excretion of >3g of protein/day, edema, hypoalbuminemia

(SEVERE)

Question 20

Nephritic syndrome

Answer 20

nephron inflammation characterized by hematuria and RBC casts, SOME proteinuria and edema

• less severe as nephrotic

Question 21

Manifestations of Nephrotic syndrome

Answer 21

edema (face, eyes, leg, ankle)
foamy urine (protein)
weight gain

Question 22

Azotemia

Answer 22

nephrotoxicity that involves excess nitrogen compounds (urea, creatinine, nitrogen-rich compounds)

• elevated BUN and creatinine
• uremic frost

can occur in all types of AKI

Question 23

Uremia

Answer 23

high levels of urea in blood
(more severe than azotemia)

TERMINAL clinical manifestation of kidney failure

CrCl <10-20mL/min

Question 24

Acute uremic symptoms

Answer 24

1. fluid/electrolyte balance dysregulation
2. increase metabolic wastes (metabolic acidosis)
3. uremic waste affecting GI tract
4. decreased platelet adhesiveness and immune response
5. metabolic waste on skin
6. decreased EPO secretion (anemia)

Question 25

AKI management

Answer 25

a. Discontinue all nephrotoxic agents when possible b. Ensure volume status and perfusion pressure (plasma expanders or diuretics) c. Consider functional hemodynamic monitoring d. Monitor serum creatinine and urine output e. Avoid hyperglycemia f. dialysis (if none else works)

Question 26

CKD Management

Answer 26

a. Management of protein intake b. Supplemental vitamin D c. Maintenance of sodium and fluid d. Restriction of potassium (prevent hyperkalemia) e. Maintenance of adequate caloric intake f. Management of dyslipidemias e. Erythropoietin as needed f. ACE inhibitors or receptor blockers g. Dialysis h. Renal transplantation

Question 27

Increase in the following is usually indicative of kidney disease

Answer 27

- BUN - serum creatinine - serum potassium

Question 28

Decrease in the following is usually indicative of kidney disease

Answer 28

- GFR - creatinine clearance - drug excretion

Question 29

Sudden causes of uremia

Answer 29

trauma, shock, toxins, acute glomerulonephritis, sepsis

Question 30

What components are needed to calculate CrCl using Cockroft Gault?

Answer 30

age BW in kg SCr in μmol/L

Question 31

What causes hyperkalemia in kidney disease?

Answer 31

a. kidney dysfunction causing inability to excrete K+ b. K+ move out of cells (metabolic acidosis) c. ACEIs d. excessive K+ intake

Question 32

Sever hyperkalemia

Answer 32

K+ >= 7.0mmol/L K+ = 6.0-6.9mmol/L with ECG changes

Question 33

What is the most appropriate treatment when hyperkalemia is accompanied by ECG changes?

Answer 33

calcium gluconate to stablize cardiac membrane

Question 34

Interventions to shift K+ into cells

Answer 34

a. insulin plus glucose (most effective! rapid acting) b. sodium bicarbonate c. inhaled salbutamol

Question 35

Interventions to remove K+ from body

Answer 35

a. sodium polystyrene - binds K+ in gut to increase GI excretion b. hemodialysis c. diuresis

Question 36

4 Key Therapeutic Strategies in management of diabetes and CKD

Answer 36

1. manage hyperlipidemia 2. control HTN 3. maintain optimal glycemic control 4. minimize proteinuria

Question 37

Causes of malnutrition in CKD

Answer 37

1. decreased oral intake 2. protein/vitamin loss from dialysis 3. low serum albumin

Question 38

What drugs should be used to manage HTN in CKD?

Answer 38

ACEIs, ARBs, CCBs Loop diuretics when CrCl <25ml/min

Question 39

What intervention is used to treat anemia in CKD?

Answer 39

blood transfusion erythropoiesis stimulating agents possibly iron supplements

Question 40

What is the target Hgb when administering ESA for anemia? What is the concern?

Answer 40

Hgb: 100-110 g/L above target could increase risk of CV event

Question 41

What causes hypocalcemia in kidney disease?

Answer 41

a. increased phosphate bind to calcium causing calcium decrease b. decreased activation of vit D causing decreased calcium absorption c. decreased calcium stimulates PTH secretion (causing body to take calcium from bone)

Question 42

pharmacokinetic alterations in renal impairment

Answer 42

- decreased absorption - decreased blood levels - increased free fraction (protein binding) - increased drug half life

Question 43

Drug dosing adjustment is based on

Answer 43

- creatinine clearance | - if >50% of drug is renally eliminated