renal pathophysiology Flashcards
(314 cards)
1
Q
Kidneys receive ____ of the total cardiac output
A
15-25%
2
Q
How much of the kidney blood flow goes to the renal cortex?
A
95%
3
Q
How much of the kidney blood flow goes to the medulla?
A
5%
4
Q
How many L/min of blood flows through the renal arteries?
A
1-1.25 L/min
5
Q
Where is the glomerulus located?
A
renal cortex
6
Q
Kidneys autoregulate their blood flow between
A
60-160 mmHg mean arterial pressures
7
Q
Autoregulation of renal blood flow is an
A
intrinsic mechanism that causes vasodilation and vasoconstriction of renal afferent arterioles
8
Q
Where does Na+ move in the nephron?
A
proximal convoluted tubule, descending loop, ascending loop, distal convoluted tubule
9
Q
where do potassium sparing diuretics work in the nephron?
A
the end of the distal convoluted tubule before the collecting duct
10
Q
where do thiazides work in the nephron?
A
beginning of the distal convoluted tubule
11
Q
where do loop diuretics work in the nephron?
A
ascending limb of the loop of Henle
12
Q
where do osmotic diuretics work in the nephron?
A
end of the proximal convoluted tubule and descending limb of the loop of Henle
13
Q
Where does Acetazlamide work in the nephron?
A
beginning of the proximal convoluted tubule
14
Q
the resistance in the efferent arterioles creates ____ within the glomerulus to provide force for _____
A
hydrostatic pressure; ultrafiltration
15
Q
the glomerular capillaries are lined with
A
endothelial cells called podocytes
16
Q
Glomerular filtration rate definition
A
the rate at which blood is filtered through all of the glomeruli measure overall kidney function
17
Q
Urinary excretion = _____ - ______ + ______
A
filtration - reabsorption + secretion
18
Q
SNS activation will _____ renal blood flow
A
reduce
19
Q
If blood pressure decreases the SNS will stimulate
A
the RAAS
20
Q
Antidiuretic hormone (ADH) is released in response to ____ stretch receptors in the atrial and arterial wall
A
decreased
21
Q
ADH is released in response to ____ osmolality of the plasma
A
increased
22
Q
osmolality is monitored by the
A
hypothalamus
23
Q
what causes an increased osmolality?
A
dehydration
24
Q
ADH is synthesized in the ____ and is released from the ____
A
hypothalamus; posterior pituitary
25
the half life of ADH is ____ minutes
16-24 minutes
26
2 primary functions of ADH
increases reabsorption of sodium and water in the kidneys
| causes vasoconstriction and PVR to increase blood pressure
27
perioperative causes of ADH release include
hemorrhage, positive pressure ventilation, upright position, nausea, medications
28
What is renin?
an enzyme secreted by the kidneys that hydrolyzes angiotensin to angiotensin I
29
where is renin released from?
the juxtaglomerular cells located near the afferent arterioles
30
what makes renin be released?
decreased arterial blood pressure
decrease in sodium load delivered to the distal tubules
SNS (beta 1 receptor)
31
angiotensin I is converted in the ___ by ____ into ____
lungs; angiotensin converting enzyme; angiotensin II
32
angiotensin II is a ___ and stimulates the ___ to secrete ____
potent vasoconstrictor; hypothalamus; ADH
33
Aldosterone is a ___ hormone released from the ____
mineralcorticoid; adrenal gland
34
plasma half life of aldosterone is
20 minutes
35
aldosterone stimulates epithelial cells in the distal tubule and collecting ducts to
reabsorb sodium and water
36
Aldosterone does the complete opposite of what hormone?
Atrial natriuretic hormone
37
Which diuretic blocks aldosterone receptors?
spironolactone (potassium sparing)
38
definition of pre-renal failure
sudden and severe drop in BP or interruption of blood flow to the kidneys from severe injury or illness
39
definition of intra-renal failure
direct damage to the kidneys by inflammation, toxins, drugs, infection, or reduced blood supply
40
definition of post-renal failure
sudden obstruction of urine flow due to enlarged prostate, kidney stones, bladder tumor, or injury
41
some causes/examples of pre-renal failure
hypoperfusion vs hypovolemia
| skin loss, fluid loss, hemorrhage, sequestration, vascular occlusion
42
pre-renal failure will activate RAAS to conserve
sodium and water
43
nephrotoxic drugs include
aminoglycosides (gentamicin, tobramycin), chemotherapeutic drugs (carboplatin, cisplatin), NSAIDs, PCNs, radiocontrast dye
44
patients with parenchymal disease will have trouble concentrating ___ leading to ___ urine sodium and ___ osmolality
urine; high; low
45
CHF and liver failure can lead to ___ ultimately causing ___
hypovolemia, decreased CO, decreased effective circulating volume; pre-renal AKI
46
NSAIDs, ARBs, ACEi, cyclosporines can lead to ___ and ultimately cause ___
impaired renal autoregulation; pre-renal AKI
47
bilateral ureteropelvic obstruction and bladder outlet obstruction leads to
post-renal AKI
48
ischemia, sepsis, and nephrotoxins can lead to ___ ultimately causing ___
acute glomerulonephritis and tubular damage; intrinsic renal AKI
49
vasculitis, TTP/HUS, and malignant HTN can lead to __ ultimately causing ___
vascular damage; intrinsic renal AKI
50
oliguric
<0.5 mL/kg/hr
51
polyuric
>2.5 L/day of non concentrated urine
52
risk for renal failure GFR criteria
increased creatinine x 1.5 or GFR decrease >25%
53
injury for renal failure GFR criteria
increased creatinine x 2 or GFR decrease > 50%
54
failure for renal failure GFR criteria
increased creatinine x3 or GFR decrease >75% or creatinine >4mg per 100 mL
55
high sensitivity urine output criteria for risk of renal failure
UO <0.5 mL/kg/hr x 6 hours
56
urine output criteria meeting injury for renal failure
UO <0.5 mL/kg/hr x 12 hours
57
high specificity urine output criteria for failure in renal failure
UO <0.3 mL/kg/hr x 24 hours or anuria x 12 hours
58
for each year after age ___ creatinine clearance decreases by ____ and renal plasma flow by ____
50; 1.5 mL; 8 mL
59
risk factors for acute renal failure/injury
age, preexisting renal dysfunction, certain surgical procedures (Cardiac bypass, aortic aneurysms, ventricular dysfunctions), sepsis (hypovolemia, hemolysis, DIC, infections, acidosis), neprhotoxic agents, diabetes, HTN
60
ways to prevent renal insult?
hydration, blood pressure control
61
3rd most common cause of hospital acquired acute renal injury
contrast induced nephropathy
62
treatment for contrast induced nephropathy
prevention is important!
supportive, careful fluid and electrolyte management
dialysis may be required in some cases
63
which kind of radiocontrast agents are the most problematic in causing contrast induced nephropathy
iodinated contrast agents
64
what are some risk factors that place a patient at increased risk of contrast induced nephropathy?
pre-existing kidney disease, DM, HTN, dehydration, obesity, only having one kidney, hepato-renal syndrome
65
as high as ___ in patients with diabetic nephropathy develop contrast induced nephropathy
50%
66
contrast induced nephropathy is worsened by ___ and ___
hypoxia and hypoperfusion
67
pathophysiology of contrast induced nephropathy
activation of cytokine induced inflammatory mediators by reactive free radicals, the excreted contrast media generates an osmotic force in the renal tubules causing an increase in sodium and water excretion which will increase intratubular pressure, reducing GFR, and contributing to the development of acute renal failure
68
oliguria is often a sign of
inadequate systemic perfusion
69
monitors to assess fluid status intraoperatively
urinary catheter, TEE, CVP, blood pressure, SVV
70
assume pre-renal oliguria is related to
FLUID until proven otherwise
71
when should diuretics NOT be given?
in the setting of intravascular hypovolemia
72
selective dopamine DA1 receptor agonists cause
renal arteriolar vasodilation
73
examples of selective dopamine DA1 receptor agonists
fenoldopam, "low dose" dopamine
74
dopamine < 3 mcg effects
modest increase in CO
increases renal blood flow
decreases proximal tubule Na+ absorption
increases splanchnic blood flow
75
dopamine 3-10 mcg effects
increases contractility
minimal change in HR and SVR
increases renal blood flow
increases splanchnic blood flow
76
dopamine > 10 mcg effects
increases HR
vasoconstriction
could increase or decrease renal and splanchnic blood flow
77
hispanic americans have a ___ greater risk for developing kidney failure than non-hispanic americans
1.5 times
78
ESRD rates nearly ___ higher among African Americans
4 fold
79
Native Americans are about ___ more likely to be diagnosed with kidney failure
1.8 times
80
what increases the risk of developing kidney disease and limit access to preventive measures and treatment in communities with socioeconomic and cultural differences?
language barriers, education and literacy levels, low income, unemployment, lack of adequate health insurance, certain culture specific health beliefs and practices
81
chronic renal failure characteristics
slow, progressive, irreversible
82
definition of chronic renal failure
decreased functioning nephrons and renal blood flow, GFR, tubular function, and reabsorptive capacity
83
common causes of chronic renal failure
glomerulonephritis, pyelonephritis, diabetes, vascular or hypertensive insults, congenital defects
84
chronic renal failure stages
decreased renal reserve
renal insufficiency
end stage renal failure or uremia
85
someone with chronic renal failure is usually asymptomatic until ___
< 40% of normal nephron remain
86
renal insufficiency in chronic renal failure is defined as
10-40% of functioning nephrons remain
| compensated, little renal reserve
87
end stage renal failure or uremia in chronic renal failure is defined as
>95% of nephrons are nonfunctioning
GFR is < 5-10% of normal
severely compromised electrolyte, hematologic, and acid-base balances, uremia is eventually lethal, dialysis dependent
88
chronic renal failure manifestations
```
hypervolemia
acidemia
hyperkalemia
cardiorespiratory dysfunction
anemia
bleeding disturbances
```
89
treatment of chronic renal failure
hemodialysis, peritoneal dialysis, kidney transplant
90
specific gravity
measurement of solutes in the urine indicating the kidneys ability to excrete concentrated urine and reflects tubular function
91
urine osmolality
number of moles of solute per kilogram of solvent
| it is more specific than specific gravity
92
ability to excrete concentrated urine indicates
good tubular function
93
proteinuria
> 150mg is excreted per day indicating failure of the renal tubules to reabsorb protein
when > 750 mg indicative of severe glomerular damage
94
urinary pH
inability to excrete an acid urine in the presence of acidosis is indicative of renal insufficiency
95
when would you see proteinuria?
pre-eclamptic patients
96
glucose is freely filtered at the
glomerulus
97
glucose is reabsorbed in the
promixal tubule
98
glycosuria signifies
that the ability of the renal tubules to reabsorb glucose has been exceeded by an abnormally heavy glucose load and is usually indicative of diabetes mellitus
99
blood urea nitrogen
not a direct renal function, is influenced by exercise, bleeding, steroids, and tissue breakdown
100
BUN is elevated in kidney disease once GFR is reduced to
75%
101
serum creatinine
muscle tissue turnover and dietary intake of protein
102
creatinine is freely filtrered at the ___ and is neither __ or ___
glomerulus; reabsorbed; secreted
103
what is the best measure of glomerular function?
glomerular filtration rate
104
normal GFR
125 mL/min
105
patients are usually asymptomatic until GFR decreases to
< 30-50% of normal
106
creatinine clearance (mL/min) =
[(140-age) x lean body weight (kg)] / [plasma creatinine (mg/dL) x 72]
107
conditions causing elevation of serum creatinine independent of GFR
ketoacidosis, cephalothin, cefoxitin, flucytosine, ASA, cimetidine, probenecid, trimethoprim
108
conditions causing decrease of serum creatinine independent of GFR
advanced age, cachexia, liver disease
109
electrocardiogram in renal disease reflects
the toxic effects of potassium excess more closely than determination of the serum potassium concentration
110
what can you give to someone who is hyperkalemic
CaCl, insulin (5-10 units), D50, albuterol, hyperventilate, RBCs, Kayexelate
111
what clinical situations contribute to increased K+ in renal failure patients?
protein catabolism, hemolysis, hemorrhage, transfusion, metabolic acidosis, exposure to meds that inhibit K+ entry into cells or K+ secretion in the distal nephron
112
during blood storage there is a slow but constant leak of ___ from the cells into the plasma as a result of ___
potassium, failure of the sodium/potassium ATPase pump
113
what do you see on ekg with hyperkalemia?
peaked T waves and/or small/indiscernible P waves
114
how long are RBCs stored in blood bank?
42 days
115
the plasma level of potassium may increase by ____ per day of refrigerator storage
0.5-1 mmol/L
116
the risk of potassium overload can be minimized by selecting
blood collected less than 5 days old and by washing the unit before infusion to remove extracellular potassium
117
the use of ___ during transfusion may also decrease potassium loading
potassium absorption filters
118
other factors that play a role in the increase of potassium levels with blood transfusions include
the patient's circulating volume, and the rate and volume of the transfusion
119
ultrasound can assess ___
kidney size, hydronephrosis, vaculature, obstructions, and masses
120
CT can assess/detect ___
stones of all kinds, masses (with contrast)
121
MRI can assess ___ and is a nice alternative to ___ and ___
detailed tissue characterization, alternative to contrast CT, reduced radiation exposure
122
what is a common agent used in MRA
gadolinium
123
general anesthesia on renal function
PPV and decreased CO leads to depression of renal blood flow, GFR, urinary flow, and electrolyte secretion
124
regional anesthesia on renal function
parallels with degree of SNS blockade, decreased venous return, and decrease in blood pressure
125
indirect perioperative effects on renal function
circulatory, endocrine, sympathetic nervous system, patient positioning
126
direct perioperative effects on renal function
medications that target renal cellular function
127
surgery effects on renal function
stress and catecholamine release, fluid shifts, secretion of vasopressin and angiotensin
128
morphine and kidney function
active metabolites depend on renal clearance mechanisms for elimination
129
how is morphine principally metabolized
by conjugation in the liver and the water soluble glucuronides are excreted via the kidney
130
what are the active metabolites of morphine?
morphine-3-glucuronide and morphine-6-glucuronide
131
meperidine's active metabolite is ___ and is dependent on ___
normeperidine; renal excretion
132
accumulation of normeperidine can lead to
CNS toxicity and seizures
133
fentanyl and kidney function
not grossly altered by renal failure but a decrease in plasma protein binding may result in higher free fractions
134
which is the opioid of choice for renal dysfunction patients
fentanyl
135
patient at risk or early stage of CKD should receive ___ doses of morphine, codeine, meperidine, hydromorphone
reduced doses
136
in someone with advanced CKD or ESRD/hemodialysis they should avoid which analgesics
morphine, codeine, meperidine
137
pregabalin and gabapentin should be ___ in CKD
given less frequently/ dosed further apart than normal
138
ketamine and CKD
8% of ketamine is metabolized by the liver forming norketamine which is then hydroxylated into a water soluble metabolite excreted by the kidney
139
most clinicians believe that dose modification for ketamine is ___ for patients with decreased renal function
not required
140
pain management in CKD stages 3 and 4
neuraxial or peripheral nerve block whenever possible
avoid NSAIDs
mild pain: tylenol +/- tramadol
moderate to severe pain: acetaminophen + opioids (fentanyl) +/- tramadol +/- ketamine
antiepileptics in neuropathic pain only
141
What is renin?
an enzyme secreted by the kidneys that hydrolyzes angiotensin to angiotensin I
142
where is renin released from?
the juxtaglomerular cells located near the afferent arterioles
143
what makes renin be released?
decreased arterial blood pressure
decrease in sodium load delivered to the distal tubules
SNS (beta 1 receptor)
144
angiotensin I is converted in the ___ by ____ into ____
lungs; angiotensin converting enzyme; angiotensin II
145
angiotensin II is a ___ and stimulates the ___ to secrete ____
potent vasoconstrictor; hypothalamus; ADH
146
Aldosterone is a ___ hormone released from the ____
mineralcorticoid; adrenal gland
147
plasma half life of aldosterone is
20 minutes
148
aldosterone stimulates epithelial cells in the distal tubule and collecting ducts to
reabsorb sodium and water
149
Aldosterone does the complete opposite of what hormone?
Atrial natriuretic hormone
150
Which diuretic blocks aldosterone receptors?
spironolactone (potassium sparing)
151
definition of pre-renal failure
sudden and severe drop in BP or interruption of blood flow to the kidneys from severe injury or illness
152
definition of intra-renal failure
direct damage to the kidneys by inflammation, toxins, drugs, infection, or reduced blood supply
153
definition of post-renal failure
sudden obstruction of urine flow due to enlarged prostate, kidney stones, bladder tumor, or injury
154
some causes/examples of pre-renal failure
hypoperfusion vs hypovolemia
| skin loss, fluid loss, hemorrhage, sequestration, vascular occlusion
155
pre-renal failure will activate RAAS to conserve
sodium and water
156
nephrotoxic drugs include
aminoglycosides (gentamicin, tobramycin), chemotherapeutic drugs (carboplatin, cisplatin), NSAIDs, PCNs, radiocontrast dye
157
patients with parenchymal disease will have trouble concentrating ___ leading to ___ urine sodium and ___ osmolality
urine; high; low
158
CHF and liver failure can lead to ___ ultimately causing ___
hypovolemia, decreased CO, decreased effective circulating volume; pre-renal AKI
159
NSAIDs, ARBs, ACEi, cyclosporines can lead to ___ and ultimately cause ___
impaired renal autoregulation; pre-renal AKI
160
bilateral ureteropelvic obstruction and bladder outlet obstruction leads to
post-renal AKI
161
ischemia, sepsis, and nephrotoxins can lead to ___ ultimately causing ___
acute glomerulonephritis and tubular damage; intrinsic renal AKI
162
vasculitis, TTP/HUS, and malignant HTN can lead to __ ultimately causing ___
vascular damage; intrinsic renal AKI
163
oliguric
<0.5 mL/kg/hr
164
polyuric
>2.5 L/day of non concentrated urine
165
risk for renal failure GFR criteria
increased creatinine x 1.5 or GFR decrease >25%
166
injury for renal failure GFR criteria
increased creatinine x 2 or GFR decrease > 50%
167
failure for renal failure GFR criteria
increased creatinine x3 or GFR decrease >75% or creatinine >4mg per 100 mL
168
high sensitivity urine output criteria for risk of renal failure
UO <0.5 mL/kg/hr x 6 hours
169
urine output criteria meeting injury for renal failure
UO <0.5 mL/kg/hr x 12 hours
170
high specificity urine output criteria for failure in renal failure
UO <0.3 mL/kg/hr x 24 hours or anuria x 12 hours
171
for each year after age ___ creatinine clearance decreases by ____ and renal plasma flow by ____
50; 1.5 mL; 8 mL
172
risk factors for acute renal failure/injury
age, preexisting renal dysfunction, certain surgical procedures (Cardiac bypass, aortic aneurysms, ventricular dysfunctions), sepsis (hypovolemia, hemolysis, DIC, infections, acidosis), neprhotoxic agents, diabetes, HTN
173
ways to prevent renal insult?
hydration, blood pressure control
174
3rd most common cause of hospital acquired acute renal injury
contrast induced nephropathy
175
treatment for contrast induced nephropathy
prevention is important!
supportive, careful fluid and electrolyte management
dialysis may be required in some cases
176
which kind of radiocontrast agents are the most problematic in causing contrast induced nephropathy
iodinated contrast agents
177
what are some risk factors that place a patient at increased risk of contrast induced nephropathy?
pre-existing kidney disease, DM, HTN, dehydration, obesity, only having one kidney, hepato-renal syndrome
178
as high as ___ in patients with diabetic nephropathy develop contrast induced nephropathy
50%
179
contrast induced nephropathy is worsened by ___ and ___
hypoxia and hypoperfusion
180
pathophysiology of contrast induced nephropathy
activation of cytokine induced inflammatory mediators by reactive free radicals, the excreted contrast media generates an osmotic force in the renal tubules causing an increase in sodium and water excretion which will increase intratubular pressure, reducing GFR, and contributing to the development of acute renal failure
181
oliguria is often a sign of
inadequate systemic perfusion
182
monitors to assess fluid status intraoperatively
urinary catheter, TEE, CVP, blood pressure, SVV
183
assume pre-renal oliguria is related to
FLUID until proven otherwise
184
when should diuretics NOT be given?
in the setting of intravascular hypovolemia
185
selective dopamine DA1 receptor agonists cause
renal arteriolar vasodilation
186
examples of selective dopamine DA1 receptor agonists
fenoldopam, "low dose" dopamine
187
dopamine < 3 mcg effects
modest increase in CO
increases renal blood flow
decreases proximal tubule Na+ absorption
increases splanchnic blood flow
188
dopamine 3-10 mcg effects
increases contractility
minimal change in HR and SVR
increases renal blood flow
increases splanchnic blood flow
189
dopamine > 10 mcg effects
increases HR
vasoconstriction
could increase or decrease renal and splanchnic blood flow
190
hispanic americans have a ___ greater risk for developing kidney failure than non-hispanic americans
1.5 times
191
ESRD rates nearly ___ higher among African Americans
4 fold
192
Native Americans are about ___ more likely to be diagnosed with kidney failure
1.8 times
193
what increases the risk of developing kidney disease and limit access to preventive measures and treatment in communities with socioeconomic and cultural differences?
language barriers, education and literacy levels, low income, unemployment, lack of adequate health insurance, certain culture specific health beliefs and practices
194
chronic renal failure characteristics
slow, progressive, irreversible
195
definition of chronic renal failure
decreased functioning nephrons and renal blood flow, GFR, tubular function, and reabsorptive capacity
196
common causes of chronic renal failure
glomerulonephritis, pyelonephritis, diabetes, vascular or hypertensive insults, congenital defects
197
chronic renal failure stages
decreased renal reserve
renal insufficiency
end stage renal failure or uremia
198
someone with chronic renal failure is usually asymptomatic until ___
< 40% of normal nephron remain
199
renal insufficiency in chronic renal failure is defined as
10-40% of functioning nephrons remain
| compensated, little renal reserve
200
end stage renal failure or uremia in chronic renal failure is defined as
>95% of nephrons are nonfunctioning
GFR is < 5-10% of normal
severely compromised electrolyte, hematologic, and acid-base balances, uremia is eventually lethal, dialysis dependent
201
chronic renal failure manifestations
```
hypervolemia
acidemia
hyperkalemia
cardiorespiratory dysfunction
anemia
bleeding disturbances
```
202
treatment of chronic renal failure
hemodialysis, peritoneal dialysis, kidney transplant
203
specific gravity
measurement of solutes in the urine indicating the kidneys ability to excrete concentrated urine and reflects tubular function
204
urine osmolality
number of moles of solute per kilogram of solvent
| it is more specific than specific gravity
205
ability to excrete concentrated urine indicates
good tubular function
206
proteinuria
> 150mg is excreted per day indicating failure of the renal tubules to reabsorb protein
when > 750 mg indicative of severe glomerular damage
207
urinary pH
inability to excrete an acid urine in the presence of acidosis is indicative of renal insufficiency
208
when would you see proteinuria?
pre-eclamptic patients
209
glucose is freely filtered at the
glomerulus
210
glucose is reabsorbed in the
promixal tubule
211
glycosuria signifies
that the ability of the renal tubules to reabsorb glucose has been exceeded by an abnormally heavy glucose load and is usually indicative of diabetes mellitus
212
blood urea nitrogen
not a direct renal function, is influenced by exercise, bleeding, steroids, and tissue breakdown
213
BUN is elevated in kidney disease once GFR is reduced to
75%
214
serum creatinine
muscle tissue turnover and dietary intake of protein
215
creatinine is freely filtrered at the ___ and is neither __ or ___
glomerulus; reabsorbed; secreted
216
what is the best measure of glomerular function?
glomerular filtration rate
217
normal GFR
125 mL/min
218
patients are usually asymptomatic until GFR decreases to
< 30-50% of normal
219
creatinine clearance (mL/min) =
[(140-age) x lean body weight (kg)] / [plasma creatinine (mg/dL) x 72]
220
conditions causing elevation of serum creatinine independent of GFR
ketoacidosis, cephalothin, cefoxitin, flucytosine, ASA, cimetidine, probenecid, trimethoprim
221
conditions causing decrease of serum creatinine independent of GFR
advanced age, cachexia, liver disease
222
electrocardiogram in renal disease reflects
the toxic effects of potassium excess more closely than determination of the serum potassium concentration
223
what can you give to someone who is hyperkalemic
CaCl, insulin (5-10 units), D50, albuterol, hyperventilate, RBCs, Kayexelate
224
what clinical situations contribute to increased K+ in renal failure patients?
protein catabolism, hemolysis, hemorrhage, transfusion, metabolic acidosis, exposure to meds that inhibit K+ entry into cells or K+ secretion in the distal nephron
225
during blood storage there is a slow but constant leak of ___ from the cells into the plasma as a result of ___
potassium, failure of the sodium/potassium ATPase pump
226
what do you see on ekg with hyperkalemia?
peaked T waves and/or small/indiscernible P waves
227
how long are RBCs stored in blood bank?
42 days
228
the plasma level of potassium may increase by ____ per day of refrigerator storage
0.5-1 mmol/L
229
the risk of potassium overload can be minimized by selecting
blood collected less than 5 days old and by washing the unit before infusion to remove extracellular potassium
230
the use of ___ during transfusion may also decrease potassium loading
potassium absorption filters
231
other factors that play a role in the increase of potassium levels with blood transfusions include
the patient's circulating volume, and the rate and volume of the transfusion
232
ultrasound can assess ___
kidney size, hydronephrosis, vaculature, obstructions, and masses
233
CT can assess/detect ___
stones of all kinds, masses (with contrast)
234
MRI can assess ___ and is a nice alternative to ___ and ___
detailed tissue characterization, alternative to contrast CT, reduced radiation exposure
235
what is a common agent used in MRA
gadolinium
236
general anesthesia on renal function
PPV and decreased CO leads to depression of renal blood flow, GFR, urinary flow, and electrolyte secretion
237
regional anesthesia on renal function
parallels with degree of SNS blockade, decreased venous return, and decrease in blood pressure
238
indirect perioperative effects on renal function
circulatory, endocrine, sympathetic nervous system, patient positioning
239
direct perioperative effects on renal function
medications that target renal cellular function
240
surgery effects on renal function
stress and catecholamine release, fluid shifts, secretion of vasopressin and angiotensin
241
morphine and kidney function
active metabolites depend on renal clearance mechanisms for elimination
242
how is morphine principally metabolized
by conjugation in the liver and the water soluble glucuronides are excreted via the kidney
243
what are the active metabolites of morphine?
morphine-3-glucuronide and morphine-6-glucuronide
244
meperidine's active metabolite is ___ and is dependent on ___
normeperidine; renal excretion
245
accumulation of normeperidine can lead to
CNS toxicity and seizures
246
fentanyl and kidney function
not grossly altered by renal failure but a decrease in plasma protein binding may result in higher free fractions
247
which is the opioid of choice for renal dysfunction patients
fentanyl
248
patient at risk or early stage of CKD should receive ___ doses of morphine, codeine, meperidine, hydromorphone
reduced doses
249
in someone with advanced CKD or ESRD/hemodialysis they should avoid which analgesics
morphine, codeine, meperidine
250
pregabalin and gabapentin should be ___ in CKD
given less frequently/ dosed further apart than normal
251
ketamine and CKD
8% of ketamine is metabolized by the liver forming norketamine which is then hydroxylated into a water soluble metabolite excreted by the kidney
252
most clinicians believe that dose modification for ketamine is ___ for patients with decreased renal function
not required
253
pain management in CKD stages 3 and 4
neuraxial or peripheral nerve block whenever possible
avoid NSAIDs
mild pain: tylenol +/- tramadol
moderate to severe pain: acetaminophen + opioids (fentanyl) +/- tramadol +/- ketamine
antiepileptics in neuropathic pain only
254
Gabapentinoids may increase the risk of
over sedation and coma
255
Gabapentinoids metabolism/elimination
excreted solely by the kidney, no hepatic metabolism
256
a reduction of ____% of the dose of gabapentinoids for each ___% decline in GFR or CCr
50%; 50%
257
how does isoflurane affect BP
decreases BP
258
desflurane can maintain
cardiac output and renal perfusion
259
what metabolite is associated with sevoflurane?
compound A and free fluoride ion metabolite
260
Co2 absorbents containing soda lime degrade _____ resulting in production of ____
sevoflurane; compound A
261
risk of production of compound A is higher with
closed circuit anesthesia
262
risk of compound A production is dependent on
duration of exposure, fresh gas flow rate, and concentration of sevoflurane
263
sevoflurane should not exceed ___ MAC hours at flow rates of ___
2; 1 to < 2 L/min
264
AMSORB is a nice alternative to soda lime because
it is non-caustic, can be disposed of in domestic waste, and there is no production of compound A even when desiccated, can use low flows with sevo
265
propofol (does/does not) adversely affect renal tubular function
does not
266
prolonged infusions of propofol may result in green urine due to the presence of
phenolic metabolites
267
propofol infusion syndrome (PRIS) can result in renal failure secondary to
rhabdomyolysis, myoglobinuria, hypotension, metabolic acidosis
268
nontoxic end products of succinylcholine
succinic acid and choline
269
succinylmonocholine is excreted
by the kidneys
270
administration of succinylcholine causes a rapid, transient increase of ____ in the serum potassium
0.5 mEq/L
271
serum potassium in renal failure patients can be elevated ____ when given succinylcholine
> 0.5 mEq/L
272
the duration of action of muscle relaxants may be _____ in renal failure patients
prolonged
273
Sugammadex is a ___ molecule that inactivates ___
cyclodextrin; aminosteroidal neuromuscular blockers
274
the resultant sugammadex- neuromuscular blocker complex is excreted
by the kidneys
275
____ is an intermediate in the metabolism of sodium nitroprusside, with ___ being the final metabolic product
cyanide; thiocyanate
276
the half life of thiocyanate is
more than 4 days normally but prolonged in renal failure
277
when thiocyanate levels are above ____ patients will experience hypoxia, nausea, tinnitus, muscle spasm, disorientation, and psychosis
10mg/100mL
278
thiocyanate toxicity is associated with ___
long term infusions >6 days
279
albumin may be protective for kidneys because
it maintains renal perfusion, binds to endogenous toxins and nephrotoxic drugs, and prevent oxidative damage
280
hetastarch and dextran have been associated with acute kidney injury secondary to
the breakdown of the synthetic carbohydrates to degradation products that cause direct tubular injury and plugging of tubules
281
dopamine and fenoldopam ___ afferent and efferent arterioles and ____ renal perfusion
dilate; increase
282
anti-dopamingerics include ___, ____, ____ and may impair renal response to dopamine
metoclopramide, phenothiazines, droperiodol
283
renal cell carcinoma originates in
the lining of the proximal tubules
284
classic triad presentation of renal cell carcinoma
hematuria, flank pain, and renal mass
285
renal dysplasia is a
malformation of the tubules during fetal development and may have ureteropelvic junction obstruction and vesicoureteral reflux
286
bilateral renal dysplasia is
incompatible with survival
287
renal dysplasia can lead to
chronic kidney disease, dialysis, and transplant
288
polycystic kidney disease is an
inherited (dominant or recessive), massive enlargement of the kidneys with compromised renal function
289
polycystic kidney disease is painful due to
distention of the cysts and stretching of fascia
| can be exacerbated by hemorrhage, rupture, or infection
290
complications from polycystic kidney disease include
hypertension due to activation of RAAS, cyst infections, bleeding, and decline in renal function
291
polycystic kidney disease treatment
symptom management, dialysis, and transplant
292
Wilms Tumor (nephroblastoma) often presents
unilaterally and as a painless, palpable abdominal mass
293
Wilms Tumor can be associated with
congenital/genetic malformations including Beckwith-Wiedemann, and Wagr
294
Wilms Tumor treatment
requires resection and possibly chemotherapy
295
metastasis with wilms tumor is usually to the
lungs
296
stage 1 wilms' tumor
43% of cases
| limited to the kidney and is completely excised
297
stage 2 wilms' tumor
23% of cases
| tumor extends beyond the kidney but is completely excised
298
stage 3 wilms tumor
20% of cases
| inoperable primary tumor or lymph node metastasis
299
stage 4 wilms tumor
lymph node metastases outside of the abdominopelvic region
300
stage 5 wilms tumor
bilateral renal involvement
301
total nephrectomy
the renal artery and vein are ligated and then it involves removal of the kidney, the ipsilateral adrenal gland, perinephric fat, and the surrounding fascia
302
partial nephrectomy
nephron sparing surgery
| for patients with a solitary functional kidney, small lesions <4cm, or bilateral tumors, or patients with diabetes/HTN
303
regional anesthesia for nephrectomy
include blockage of nerve roots T8-L3
304
PTH increases ___ reabsorption in exchange for ____
Ca++; phosphate
305
erythropoietin is released by ___ in response to anemia and hypoxia
the kidneys
306
aldosterone is secreted from the ___ and causes reabsorption of ___
adrenal cortex; Na+
307
ADH/vasopressin will ___ efferent arteriole and causes reabsorption of ___
constrict; water
308
ANP stimulates excretion of ___ and ___
Na+ and water
309
dopamine acts on ___ in the renal vasculature and causes ___
DA1 receptor; vasodilation and Na+ excretion
310
the kidneys filter the blood ___ per day
20-25 times per day
311
each kidney has about ____ nephrons
1 million
312
if the nephrons in the kidneys were removed and laid end to end they cover a distance of
10 miles
313
Kidney awareness month
march
314
if one of the kidneys is taken out how much kidney function is lost?
only 25%
