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Renal Patho, Diuretics and Anesthesia Flashcards

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1
Q

What are involved in the long-term regulation of sodium and water balance, blood volume and arterial pressure.

A

Naturetic Peptide

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2
Q

What are two major pathways (actions) of natriuretic peptide actions?

A

1) vasodilator effects

2) renal effects that leads to natriuresis and diuresis

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3
Q

NPs directly dilate veins (increasevenous compliance) and thereby decrease_______ which reduces cardiac output by decreasingventricular preload. NPs also dilate arteries, which decreases_______ and ______

A

central venous pressure,

systemic vascular resistance

systemicarterial pressure.

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4
Q

ANP affects the kidneys by increasing glomerular filtration rate (GFR) and filtration fraction, which produces

A

Natriuresis (increased NA excretion)

diureses

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5
Q

Natriuretic peptides decrease _____ release which decreasing circulating levels of_____ & ____

A

renin

angiotensin IIand aldosterone

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6
Q

NP serves as a ______ system for the renin-angiotensin-aldosterone system.

A

counter-regulatory

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7
Q

ANP is produced where? and what is its stimulus for release?

A

Produced by atrial myocytes

Atrial stretch ( increased ECV)

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8
Q

What 2 things does ANP inhibit?

A

renin release and aldosterone secretion

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9
Q

ANP acts directly on the collecting duct to

A

decrease NaCl reabsorption

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10
Q

ANP inhibits ____ release from the posterior pituitary

A

ADH

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11
Q

What is the basic definition of a diuretic?

A

A substance that increases the rate of urine volume output.

Most clinically used diuretics act by decreasing the rate of sodium reabsorption from the tubules which causes sodium output to increase (natriuresis) which then results in diuresis (water output)

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12
Q

T/F: many diuretics work within minutes this effect decreases over the next few days with chronic use

A

True

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13
Q

What are examples of osmotic diuretics?

A

urea or mannitol

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14
Q

how do osmotic diuretics work?

A

These substances, if injected into the bloodstream are filtered and not easily reabsorbed, they draw fluid into the tubules

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15
Q

Examples of loop diuretics

A

furosemide (Lasix)
bumetanide (Bumex)
ethacrynic acid

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16
Q

Where do loop diuretics work and how?

A

in the THICK ascending loop

inhibit the Na-2Cl-K co-transporter

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17
Q

Why does inhibition of the Na-2KCl-K co transporter pump by loop diuretics work?

A

This transporter normally reabsorbs about 25% of the sodium load

Increased delivery of solutes to the distal tubule due to inhibited reabsorption, these solutes act as osmotic agents to draw fluid into the tubule

The countercurrent multiplier system is disrupted and the interstitium cannot become hyperosmolar (hyperosmolar would pull fluid in)

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18
Q

What are the most commonly used diuretics?

A

thiazide diuretics

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19
Q

What is an example of thiazide diuretics?

A

hlorothiazide (abbreviated HCTZ

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20
Q

Where do thiazide diuretics work?

A

inhibit sodium chloride reabsorption in the EARLY DCT

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21
Q

what ions get wasted when diuretic use and what does it lead to

A

H and K wasting - leads to metabolic alkalosis

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22
Q

What is an example of a carbonic anhydrase inhibitor

A

acetazolamide (Diamox)

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23
Q

Where does Carbonic anhydrase inhibitors work?

A

Reduce reabsorption of Na+ in the PCT by decreasing bicarbonate reabsorption

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24
Q

What is the disadvantage of Carbonic anhydrase inhibitors

A

it causes acidosis through bicarbonate loss in the urine.

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25
What is the MAIN use of Carbonic anhydrase inhibitors
Their main use is in the treatment of glaucoma***
26
What are aldosterone antagonist diuretics?
potassium sparing diuretics
27
What are examples of potassium sparing diuretics
spironolactone (Aldactone)
28
What do potassium sparing diuretics work?
Decreases reabsorption of Na+ and decreases K+ secretion by competing for aldosterone binding sites in the DISTAL segment of the DCT
29
What are examples of Na Channel blockers?
amiloride and triamterene
30
How and where do Na channel blockers work?
Decrease activity of Na/K ATPase in the COLLECTING TUBULES and thereby decrease Na+ reabsorption These diuretics also “spare” potassium
31
What are the 2 types of renal failure
AKI - abrupt loss of kidney function within a few days (can eventually recover near normal kidney function) CKD - An irreversible decrease in the number of functional nephrons.
32
What is the main cause of ESRD?
Diabetes followed by HTN | obesity underlying cause of both
33
What is AKI: pre-renal
Kidney not getting enough blood flow and therefore becomes ischemic (abnormality originating outside the kidneys) Examples: heart failure, hypovolemia
34
What is AKI: intra-renal
Damage to the kidney itself (rom abnormalities within the kidney itself) Examples: Toxins, infections, autoimmune disease, direct renal injury
35
What is AKI: post-renal
Obstruction of the collecting system (from obstruction of the urinary collecting system anywhere from the calyces to the outflow from the bladder) Stones, urethral valves, tied off ureter, kinked Foley
36
Symptoms of CKD often do not occur until the number of functioning nephrons decreases to at least ___ below normal.
70%
37
CKD is usually defined as the presence of kidney damage or decreased kidney function that persists for at least _______
3 months
38
Relatively normal blood concentrations of most electrolytes and normal body fluid volumes can still be maintained until the number of functioning nephrons decreases below ______ of normal.
20-25%
39
Some common causes of chronic renal failure
DM, HTN, renal vascular disorders, immunologic disorders, infections, primary tubular disorders, urinary tract obstruction, congenital abnormalities (many more - these are most prominent)
40
What is a common renal vascular abnormality?
Nephrosclerosis (refers to sclerotic lesions of smaller arteries, arterioles, and glomeruli - Atherosclerosis of large vessels - Fibromuscular dysplasia
41
What is Glomerulonephritis and what can cause it
Most commonly caused by deposition of antigen-antibody complexes in glomerular membranes Can be post-streptococcal infection & Lupus
42
What is nephrotic syndrome
Condition where large amounts of protein are lost in the urine due to destruction of or loss of negative charge on the capillary basement membrane in the glomerulus
43
Renal failure leads to uremia. What are symptoms of this
- generalized edema - acidosis - high concentrations of waste products urea, creatine, uric acid - increase K, phosphates, phenols - Anemia occurs because of decreased synthesis by the kidney of erythropoietin - Cardiac output often increases to compensate for decreased oxygen carrying capacity.
44
Why do patients in RF and ESRD have increased minute ventilation?
to compensate for acidosis
45
What is osteomalacia?
serious damage to the kidney greatly reduces the blood concentration of active vitamin D, which in turn decreases intestinal absorption of calcium and the availability of calcium to the bones Rise in serum phosphate increases binding of phosphate with calcium in the plasma, thus decreasing the plasma serum ionized calcium concentration, which, in turn, stimulates parathyroid hormone secretion = secondary hyperparathyroidism
46
Hypertension and the kidneys: how does a kidney lesion effect BP
Kidney lesions which decrease water and sodium excretion promote hypertension Hypertension allows water and sodium excretion to return toward normal If one kidney or part of one is ischemic or damaged the normal kidney gets punished. Renin and angiotensin II from the ischemic kidney affect the normal kidney and also drives up BP
47
Effective treatment of hypertension requires enhancing the kidneys’ capability to
excrete salt and water either by increasing GFR or by decreasing tubular reabsorption
48
What diuretic do you give for HTN
Diuretic drugs that directly inhibit renal tubular reabsorption of salt and water.
49
What does the rate of movement of solute across this membrane depends on
the concentration gradient of the solute permeability and surface area of the membrane length of time the blood and fluid remain in contact with the membrane
50
how many cc’s of blood are in the dialysis machine at one time
500
51
What substances are not contained in dialyzing fluid
no phosphate, urea, urate, sulfate, or creatinine
52
Indications for dialysis
``` Fluid overload Hyperkalemia Severe acidosis Metabolic encephalopathy Pericarditis Coagulopathy Refractory GI symptoms Drug toxicity ```
53
Normal BUN
10-20
54
Ammonia is converted to urea in the ___ and urea is handled by the _____
liver kidney
55
40-50% of urea is passively reabsorbed in the nephron, but what will increase this
hypovolemia
56
what causes an increased BUN
decreased GFR or increased protein breakdown
57
normal Cr levels
Men: 0.8-1.3 mg/dL Woman: 0.6-1.0
58
What is Cr
A byproduct of muscle metabolism of creatine
59
Creatinine concentration is directly related to ______ and is inversely related to ____
body muscle mass GFR
60
What is CrCl used to measure
A way to measure GFR GFR decreases with age in most people (5% decline per decade after age 20) Because muscle mass also usually declines with age the serum creatinine level remains stable
61
BUN creatinine ratios > __ are seen in volume depletion or conditions associated with decreased tubular flow and obstructive uropathy
10:1
62
A specific gravity > 1.018 after an overnight fast is indicative of
adequate urinary concentrating ability
63
A low specific gravity in the face of plasma hyperosmolality is consistent with
diabetes insipidus
64
Urinary pH > 7.0 in the presence of systemic acidosis is suggestive of
renal tubular acidosis
65
How do renal patients handle barbiturates
patients with renal disease are more susceptible to these agents probably because of decreased protein binding (more free drug available)
66
How do renal patients handle Propofol, ketamine, and etomidate:
no significant differences in uremic patients | okay to give
67
how do renal patients handle benzos
metabolized by liver, most are protein bound so may be additional sensitivity, extra caution with diazepam (Valium) as active metabolites can accumulate.
68
how do renal patients handle precedex?
primarily metabolized in the liver Volunteers with renal impairment receiving dexmedetomidine experienced a longer-lasting sedative effect than subjects with normal kidney function
69
Morphine, meperidine (demerol) and hydromorphone in renal patients
active metabolites can cause problems
70
What opioid should you give renal patients
fentanyl
71
are anticholinergics okay with renal patients?
Atropine and glyco can be used safely though metabolites may accumulate with repeated dosing
72
Is reglan safe to give to renal patients?
Is partly excreted unchanged by the kidney, can accumulate in renal failure but is generally safe to use in a single dose.
73
T/F: Muscle relaxants are the most likely group of drugs used in anesthetic practice to produce prolonged effects in ESRD because of their dependence on renal excretion
TRUE
74
Why is there concern using SEVO with renal patients?
nephrotoxic - compound A | just keep flows >2L
75
Can success be given to renal patients?
safe in patients with K<5.0 mEq/L, will transiently increase K+ by almost 0.5 mEq/L
76
What muscle relaxant should you give to renal patients?
Drug of choice is Cis-atracurium as it is degraded by Hoffman elimination
77
What agents should you avoid with renal patients
pancuronium, pipecuronium, alcuronium, doxacurium as these are primarily dependent on renal excretion
78
are Roc and Vec okay in renal patients?
are primarily eliminated by the liver but there is some mild prolongation in R.F.
79
How is Cis-atracurium reversed
glyco
80
technically should you give roc to renal patients?
no but studies showed it was okay
81
at what K will will a surgery still be performed? at hat level does the patient need dialyzed?
<5.5 >5.5
82
How long should dialysis be performed before surgery
6-8 hrs
83
Factors contributing to hyperkalemia in CKD
potassium intake K released from intracellular stores K excretion (look at slide 54)
84
Why should you use invasive monitoring in these patients?
Invasive hemodynamic monitors often indicated this is a high morbidity group of patients (Pts with DM and RF have 10x the periop morbidity of patients with DM and no RF)
85
What fluid should you avoid in CKD patients?
best to avoid LR as it has 4mEq/L of K+
86
What type of ventilation should you use with these patients?
Controlled ventilation may be advantageous as it will decrease the risk of respiratory acidosis which is not good in the setting of metabolic acidosis.
87
What is a key factor in the causation of periop renal failure
hypovolemia (hydrate your patients!)
88
risk factors for peri-op renal failure
``` Sepsis Hypovolemia Obstructive jaundice Aminoglycoside antibiotics Nsaids ACE inhibitors Recent dye injections ```
89
What will happen with a patient on ace inhibitors peri-op
(more hypotensive than normal, maybe need more meds – hydrate your patients prior)***
90
What is the first thing you should check when you patient is oliguric during surgery
First make sure the foley is patent and not kinked
91
What is the most common type of kidney stone
Calcium Oxalate Stones
92
What is ESWL
Used for disintegration of stones in the kidney or ureter above the level of the illiac crest
93
When is the shock for ESWL timed?
Shock waves are timed 20 ms after the r wave so it is delivered during the ventricular refractory period
94
how to prevent stone formation
Drink water Avoid cola beverages Limit protein, nitrogen and sodium in diet
95
A diet rich in what leads to gout
More common where diet rich in protein, fat and alcohol
96
Why might CPAP help with gout
Gout associated with sleep apnea (O2 starved cells die and release uric acid)

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