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AS - N935 Advanced Patho II > Renal Pathophysiology > Flashcards

Renal Pathophysiology Flashcards

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1
Q

Kidneys receive ___% total CO

A

15-25%

95% directed to the renal cortex (glomerulus)
5% to the medulla

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2
Q

Renal Autoregulation

A

INTRINSIC - intact even in denervated kidneys

Tubuloglomerular feedback

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3
Q

Renal Blood Flow

A

Afferent arteriole → glomerular capillary → Bowman’s capsule → proximal tubule → loop of Henle descending → ascending → macula densa → distal tube collecting duct

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4
Q

Glomerulus

A

Separates the afferent from efferent arterioles
Resistance in efferent arterioles creates hydrostatic pressure w/in glomerulus
Capillaries lined w/ podocytes

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5
Q

GFR

A

Glomerular filtration rate
Rate blood filtered through all glomeruli
Measures overall kidney function

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6
Q

SNS Activation

A

↓RBF
Blood shunted to skeletal muscle during exercise
Surgical stimulation ↑vascular resistance
Stimulates adrenal medulla → catecholamine release
↓BP → RAAS activation

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7
Q

ADH

Vasopressin

A 
Antidiuretic hormone
Released in response to ↓stretch receptors in atrial/arterial wall & ↑plasma osmolality
Synthesized in hypothalamus
Released from posterior pituitary
Half-life 16-24 minutes
Constrict efferent arteriole
H2O reabsorption
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8
Q

ADH Primary Functions

A
  1. ↑renal H2O reabsorption (osmolality)

2. Vasoconstriction ↑SVR ↑BP

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9
Q

Periop Release ADH Causes

A 
Hemorrhage
PPV +
Upright position
Nausea
Medications
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10
Q

Renin

A 
Enzyme secreted by kidneys
Hydrolyzes angiotensin → angiotensin I
Released from JG cells near afferent arterioles
- ↓arterial BP
- ↓Na+ load delivered to distal tubules
- SNS β1 receptors
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11
Q

Angiotensin

A

Angiotensin I converted in the lungs by ACE into angiotensin II
Angiotensin II potent vasoconstrictor & stimulates hypothalamus to secrete ADH

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12
Q

Aldosterone

A

Mineralocorticoid hormone released from the adrenal gland
Plasma half-life 20 minutes
Stimulates epithelial cells in distal tubule & collecting ducts to reabsorb Na+ & H2O (exchanges K+ to maintain electroneutrality)

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13
Q

Spironolactone

A

K+ sparing diuretic that blocks the aldosterone receptors

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14
Q

Acute Renal Failure

AKI

A

Sudden inability to produce urine
Develops rapidly but may resolve
50% mortality rate

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15
Q

Pre-Renal

A

Hemodynamic or endocrine factors impair perfusion
Causes - hypotension, shock, hypovolemia, hemorrhage, burns (fluid shift), vascular occlusion (thrombosis or clamping), ↓RBF (heart failure or renal artery stenosis), hepato-renal syndrome
Activate RAAS → ADH
Low urine Na+ ↑osmolality
Possible to progress to permanent parenchymal damage

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16
Q

Intra-Renal

Acute Tubular Necrosis

A

Direct kidney tissue damage
Causes - inflammation/infection, reduced blood supply, prolonged ischemia, nephrotic injury (antibiotics, chemo, contrast dye), glomerulonephritis
Parenchymal disease difficult to concentrate urine
↑urine Na+ ↓osmolality

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17
Q

Post-Renal

A

Urinary outflow obstruction
Causes - kidney stones (calculi), stricture, blood clots, neoplasm, bladder/pelvic tumor, prostate enlargement, or injury
Less common in OR setting

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18
Q

Anuria

A

<100mL/day

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19
Q

Oliguria

A

<400mL/day
<0.5mL/kg/hr

OR oliguria indicates inadequate systemic perfusion

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20
Q

Polyuria

A

> 2.5L/day

Non-concentrated urine

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21
Q

Acute Renal Failure

AKI Risk Factors

A

↓renal reserve w/ age
Each year after 50 creatinine clearance ↓1.5mL & renal plasma flow ↓8mL
Pre-existing renal dysfunction
Surgical procedures
- Cardiac bypass >2 hours
- Aortic aneurysms (supra-renal aortic clamping)
- Ventricular dysfunctions
Sepsis - hypovolemia, hemolysis, DIC, infections, acidosis
Nephrotoxic agents
Diabetes
Hypertension

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22
Q

AKI Prevention

A

Prevention renal insult more successful than management
Hydration
Maintain blood pressure
Euvolemia

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23
Q

Contrast-Induced Nephropathy

A

3rd most common cause hospital acquired AKI
Results from iodinated contrast media admin
Transient & reversible acute renal failure
1° supportive treatment
- Fluid & electrolyte management
- Dialysis
Low incidence in normal renal function patients 0-5%
Pre-existing renal impairment 12-27%
Diabetic neuropathy up to 50%

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24
Q

CIN Risk Factors

A 
Pre-existing renal disease
Diabetes
Hypertension
Volume-status (dehydration)
Obesity
Hepato-renal injury
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25
CIN Pathology
Unclear Hypoxia & hypo-perfusion exacerbate injury Direct contrast media toxicity r/t harmful effects free radicals & oxidative stress Excreted contrast in renal tubules generates osmotic force causing ↑Na+/H2O excretion Diuresis ↑intratubular pressure ↓GFR → acute renal failure
26
CIN Treatment
Supportive Prevention = key Contrast media diagnostic studies or interventional procedures weigh risk against benefit
27
Intraop Monitors
``` Rapid recognition & treatment to prevent renal insult Foley Transesophageal echocardiogram CVP (less accurate) Blood pressure Stroke volume variation ```
28
Oliguria Treatment
Assume pre-renal oliguria r/t fluid until proven otherwise Blood Selective dopamine receptor agonists cause renal arteriolar vasodilation - Fenoldopam & low-dose dopamine <3mcg/kg Diuretics - Furosemide or Mannitol (do not admin in patient w/ intravascular hypovolemia)
29
Chronic Renal Failure
Slow, progressive, & irreversible ↓nephron function ↓RBF ↓GFR Causes - glomerulonephritis, pyelonephritis, diabetes, vascular or hypertensive insults, or congenital defects
30
Renal Insufficiency
↓renal reserve asymptomatic until <40% normal nephron remain Insufficiency when 10-40% functioning nephrons remain Compensated w/ minimal renal reserve
31
ESRD
End-stage renal disease/failure >95% nephrons non-functioning GFR <5-10% normal Severely compromised electrolyte, hematologic, & acid-base balance Uremia - urine in the blood eventually lethal Dialysis dependent
32
Chronic Renal Failure S/S
``` Hypervolemia Acidemia Hyperkalemia Cardiorespiratory dysfunction Anemia Bleeding disturbances ```
33
Chronic Renal Failure Treatment
Hemodialysis HD Peritoneal dialysis PD Kidney transplant
34
Urine Specific Gravity
Measure solutes present in urine Indicates kidneys ability to excrete concentrated urine Reflects tubular function
35
Urine Osmolality
Number moles solute per kilogram solvent More specific than specific gravity Ability to excrete concentrated urine indicates adequate tubular function
36
Proteinuria
>150mg excreted per day >750mg (3+ or 4+) indicates severe glomerular damage Failure renal tubules to reabsorb protein
37
Urinary pH
Inability to excrete an acid urine in presence acidosis | Indicates renal insufficiency
38
Glucose
Freely filtered at glomerulus Reabsorbed in proximal tubule Glycosuria indicates renal tubules ability to reabsorb glucose exceeded by abnormally heavy glucose load Indicates diabetes mellitus
39
BUN
Blood urea nitrogen Not direct renal function Influenced by exercise, bleeding, steroids, & tissue breakdown Elevated in kidney disease when GFR reduced to 75%
40
Serum Creatinine
Muscle tissue turnover & dietary protein intake Creatinine freely filtered at glomerulus & neither reabsorbed nor secreted Creatinine clearance measures GFR
41
↑Creatinine
Ketoacidosis Cephalothin/Cefoxitin Flucytosin Other drugs - ASA, cimetidine, probenecid, trimethoprim (inhibit tubular creatinine secretion)
42
↓Creatinine
Advanced age (elderly) physiologic ↓muscle mass Cachexia pathologic ↓muscle mass Liver disease ↓hepatic creatinine synthesis
43
GFR
Glomerular filtration rate Best measure glomerular function Normal 125mL/min ASYMPTOMATIC until GFR decreases to <30-50% normal
44
Hyperkalemia
Peaked T waves | Small or indiscernible P waves
45
PRBCs
Blood storage → constant potassium leak Potassium ↑0.5-1mmol/L per day refrigerator storage Blood stored in blood bank up to 42 days
46
Minimize Transfusion Hyperkalemia Risk
Select blood collected <5 days prior to transfusion Wash blood immediately before infusion to remove extracellular potassium K+ absorption filters during transfusion to decrease K+ loading Rate & volume contribute to K+ levels as well as patient pre-transfusion circulating blood volume
47
General Anesthesia
PPV ↓CO | ↓RBF, GFR, urinary flow, & electrolyte secretion
48
Regional Anesthesia
Parallels w/ SNS blockade degree | ↓VR ↓BP
49
Direct & Indirect Effects
``` Direct: - Medications that target renal cellular function Indirect: - Circulatory - Endocrine - SNS - Patient positioning ```
50
Surgery Impact on Renal Disease
Stress & catecholamine release Fluid shifts Vasopressin & angiotensin secretion
51
Opioids
Morphine - active metabolites depend on renal clearance Meperidine - normeperidine active metabolite Fentanyl ↓plasma protein binding ↑free fraction available CKD ↓opioid dosages
52
Ketamine
Hepatic metabolism Norketamine metabolite hydroxylated into water-soluble Renal excretion
53
Gabapentinoids
Gabapentin (Neurontin) & Pregabalin (Lyrica) Solely renal excretion ↓dose 50% each 50% ↓GFR ↑time interval b/w doses
54
Inhalational Agents
Hypotension → compensatory ↑renal vascular resistance ↓RBF Isoflurane ↓BP (dose-dependent) Desflurane ↓BP ↑HR maintain CO & renal perfusion Sevoflurane - free fluoride ion metabolite
55
Compound A
CO2 absorbents containing soda lime (KOH, NaOH, H2O, CA(OH)2) degrade Sevoflurane resulting in production vinyl ether Higher risk w/ closed-circuit anesthesia Dependent on duration exposure, FGF, & concentration
56
Propofol
Does not adversely affect renal tubular function Prolonged infusion → green urine d/t presence phenolic metabolites Discoloration does not affect renal function PRIS - renal failure 2° rhabdomyolysis, myoglobinuria, hypotension, metabolic acidosis
57
Succinylcholine
Careful admin Rapid transient ↑K+0.5mEq/L Metabolism pseudocholinesterase → succinic acid & choline Metabolic precursor succinylmonocholine renal excretion Preop & postop dialysis w/in 24 hours
58
NDMRs
Prolonged elimination 1/2 life Vecuronium 0.9 → 1.4hr 30% renal excretion Atracurium 0.3 → 0.4hr (Hoffman elimination) Pancuronium 1.7 → 8.2hr Rocuronium 0.7 → 1hr Mivacurium 0.03 → 0.06hr
59
Sugammadex
Cyclodextrin molecules inactivate aminosteroidal NMBs Renal excretion Cyclodextrin complexes accumulate in severe renal impairment Insufficient data concerning long-term exposure
60
Sodium Nitroprusside
Nitroprusside → cyanide → thiocyanate | Thiocyanate 1/2 life >4 days (prolonged in renal failure)
61
Thiocyanate Toxicity
Levels >10mg/100mL Associated w/ long-term infusions >6 days Hypoxia, nausea, tinnitus, muscle spasm, disorientation, & psychosis
62
Albumin
Protective | Maintains renal perfusion, binds endogenous toxins, nephrotoxic drugs, & prevents oxidative damage
63
Hetastarch/Dextran
Associated w/ AKI 2° breakdown synthetic carbohydrates to degradation products that cause direct tubular injury & tubules plugging Worsened w/ ↓renal perfusion
64
Dopaminergics
Fenoldopam selective D1 agonist Low-dose dopamine Dilate afferent & efferent arterioles ↑renal perfusion
65
Anti-Dopaminergics
Metoclopramide, Droperidol, & phenothiazines Impair renal response to dopamine
66
Renal Cell Carcinoma
``` Most common renal malignancy 80% all solid renal masses Originates in proximal tubules lining Refractory to chemotherapy or radiation Classic triad presentation Surgical resection often curative ```
67
Classic Triad Presentation
Hematuria Flank pain Renal mass
68
Renal Dysplasia
Renal tubules malformation during fetal development Irregular cysts Utero diagnosis via ultrasound Bilateral incompatible w/ survival 90% patients have contralateral hypertrophy as adults (healthy kidney compensation) → CKD, dialysis, transplant
69
Polycystic Kidney Disease
Inherited (dominant or recessive) renal enlargement w/ compromised function Non-functioning fluid filled cysts microscopic to mass-effect size Cysts present on other organs (liver, pancreas, spleen) Painful d/t cyst distension & fascia stretching - Hemorrhage, rupture, or infection exacerbate pain
70
PKD Complications
HTN d/t RAAS activation Cyst infections Bleeding Decline in renal function
71
PKD Treatment
Symptom management Dialysis Transplant
72
Wilm's Tumor
Nephroblastoma Unilateral painless, palpable abdominal mass Associated w/ congenital/genetic malformations Most common pediatric malignant renal tumor 1/3 occur under 1yo Resection & possible chemo RAPID growth Metastasis → lungs
73
Wilm's Tumor | Stage 1
43% Limited to kidney Completely excised
74
Wilm's Tumor | Stage 2
23% | Tumor extends beyond kidney but completely excised
75
Wilm's Tumor | Stage 3
20% | Inoperable primary tumor or lymph node metastasis
76
Wilm's Tumor | Stage 4
Lymph node metastases outside abdominopelvic region
77
Wilm's Tumor | Stage 5
Bilateral renal involvement
78
Total Nephrectomy
Renal artery & vein ligated Remove kidney, ipsilateral adrenal gland, perinephric fat, & surrounding fascia Other kidney needs to be functional
79
Partial Nephrectomy
Nephron sparing surgery Patients w/ solitary functional kidney, small lesions <4cm, or bilateral tumors ↑risk patients d/t other comorbidities diabetes or HTN Open, laparoscopic, and/or robotic
80
Nephrectomy | Anesthetic Considerations
``` Type + cross CBC & electrolytes Regional anesthesia nerve roots T8-L3 ERAS Opioid sparing ```
81
Parathyroid Hormone
↑Ca2+ reabsorption | Exchange phosphate
82
Erythropoietin
Released from kidney in response to anemia or hypoxemia
83
ANP
Atrial natriuretic peptide Fluid overload → atrial distension Stimulates Na+ & H2O excretion
84
Dopamine
DA1 receptor Located in renal vasculature Vasodilation & Na+ excretion
85
Nephrons
Each kidney has 1 million nephrons | 2 kidney nephrons end-to-end 10 miles
86
Kidneys filter blood _____ times per day
20-25x per day
87
Renal Agenesis
Born w/ one kidney or kidney removed | Body only loses 25% kidney function d/t hypertrophy to sustain the body

AS - N935 Advanced Patho II (20 decks)

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