Test #1 Flashcards

(139 cards)

1
Q

Azotemia

A

Elevated BUN/Creatinine

The buildup of abnormally large amounts of nitrogenous waste products in the blood

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2
Q

Types of azotemia

A

Pre-renal failure

Intrinsic renal failure

Post-renal obstruction

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3
Q

Oliguria

A

Urine output < 400 mL/day

Urine output < 20 cc/hr

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4
Q

Anuria

A

Urine output < 100 mL/day

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5
Q

Glomerular filtration rate (GFR)

A

The sum filtering rate of all functioning neurons

-Kidney filtration rate

Measure Creatinine, Urea, or Inulin clearance

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6
Q

GFR Normals by gender

A

Men = 130 mL/min/173 m2

Women = 120 mL/min/173 m2

Decrease normally w/ age

Influenced by age, sex, body size, and renal blood flow

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7
Q

Creatinine clearance

A

Assess GFR

Normals: Men = 107-139

-Women = 87-107

Can overestimate the GFR by 40%, especially with decreased renal function

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8
Q

Major body cations and normal values

A

Sodium: 135-145

Potassium: 3.8-5.5

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9
Q

Major body anions and normal values

A

Chloride: 98-106

Bicarbonate: 21-28

Total CO2: 23-30

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10
Q

Typically secreted electrolytes

A

Hydrogen

Potassium

Urate

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11
Q

Odors indicate:

Ammonia-like

Foul/offensive

Sweet

Fruity

Maple syrup-like

A

Ammonia-like: Urea-splitting bacteria

Foul/offensive: Old, pus, inflammation

Sweet: Glucose

Fruity: Ketones

Maple syrup-like: Maple syrup urine disease

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12
Q

Colors indicate:

Colorless

Deep yellow

Yellow-green

Red

Brownish-red

Brownish-black

A

Colorless: Dilute urine

Deep yellow: Concentrated urine

Yellow-green: Bilirubin

Red: Blood/Hemoglobin

Brownish-red: Acidified blood (acute glomerulonephritis)

Brownish-black: Homogentisic acid (Melanin)

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13
Q

Globulinuria DDx

A

Glomerulonephritis

Tubular dysfunction

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14
Q

Bence Jones proteinuria DDx

A

Multiple myeloma

Leukemia

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15
Q

Fibrinogen proteinuria DDx

A

Severe renal disease

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16
Q

Types of ketone bodies

A

Acetoacetic acid

Acetone

Betahydroxybutyric acid (most common)

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17
Q

Nephrotic syndrome vs nephritic syndrome

A

Lots of protein loss w/ nephrotic

Lots of blood loss w/ nephritic

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18
Q

Acute renal failure

Heath’s intro

A

Abrupt kidney function loss w/in 7 days

Pre-renal, intrinsic, or post-renal

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19
Q

Chronic kidney disease

Heath’s intro

A

Progressive renal function loss over months/years

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20
Q

End-stage renal disease

Heath’s intro

A

Chronic kidney disease at stage 5 progression

GFR <15

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21
Q

Glomerulopathy

Heath’s intro

A

Disease of glomeruli or nephron

Can be inflammatory or non-inflammatory

Nephritic syndrome, IgA nephropathy, Nephrotic syndrome

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22
Q

Hydrostatic vs osmotic pressure

A

Hydrostatic pressure pushes fluid into the interstitium

Osmotic pressure pushed fluid from interstitium back into capillary/tubule

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23
Q

Fluid and electrolyte intake and output regulation

A

Fluid intake - hypothalamus regulates thirst

Electrolyte intake - dietary habits regulate

Output of both is regulated by kidneys

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24
Q

Mechanisms to stimulate hypothalamic thirst center

A

Increased plasma osmolality (Dry mouth and osmoreceptors stimulated)

Decreased plasma volume (RAAS and decreased BP)

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25
ADH stimulation and mechanism
Stimulated by dehydration, increase in osmolality, or RAAS Increases water absorption by increasing the number of aquaporins in the collecting tubule
26
Kidney blood vessel order
Aorta - renal artery - segmental artery - interlobar artery - arcuate artery - cortical radiate artery - afferent arteriole - glomerulus Glomerulus - efferent arteriole - peritubular capillaries and vasa recta - cortical radiate vein - arcuate vein - interlobar vein - renal vein - inferior vena cava
27
Renal clearance
Volume of plasma completely cleared of waste by kidneys per minute Clearance = (Urine concentration \* urine flow rate) / plasma concentration Can be used to estimate GFR if substance excreted is freely filtered w/o absorption
28
Renal autoregulation
Allows GFR to remain stable in spite of arterial blood pressure changes Afferent and efferent arterioles change resistance to modify GFR and blood flow Myogenic response and tubuloglomerular feedback (macula densa)
29
Feedback that triggers an increase in GFR
Prostaglandins Fever/pyrogens Glucocorticoids Hyperglycemia (DM) Macula densa senses low NaCl
30
Feedback that triggers a decrease in GFR
NSAIDs Aging (10% decline/decade after 40 years)
31
PCT
Most reabsorption of vital substances - glucose, aa, bicarb, Na, Cl, water Ammonia is generated and secreted here Mannitol and acetazolamide diuretics work here Angiotensin II increases sodium and water reabsorption PTH increases phosphate excretion
32
Transport maximum
Some substances (glucose) can only be absorbed to a certain threshold, and all excess gets excreted
33
Loop of Henle - thin descending loop
Water is passively absorbed here Loop is impermeable to sodium and solutes (medulla hypertonicity)
34
Loop of Henle - ascending loop
Not permeable to water, but active electrolyte reabsorption occurs here w/ Na/K/Cl pump Loop diuretics (Lasix) work here to shut down pump and produce very dilute urine The high osmotic gradient created here allows for urine concentration later
35
DCT
Subjected to hormonal control (Aldosterone, ADH, Angiotensin II, ACEI, ANP) Early DCT only electrolytes permeable Late DCT and CT - ADH controls water permeability -principal and intercalated cells assist w/ concentration here
36
Aldosterone
Secreted from adrenal gland Increases sodium absorption and potassium secretion in order to maintain blood volume and pressure Triggered by RAAS
37
Angiotensin II
End of RAAS Causes Aldosterone, ADH release Also causes arterial constriction, increases GFR and increases thirst Results in BP increase, water retention, and increased fluid intake
38
ACEI/ARB effect on kidneys
Inhibits RAAS - decreased aldosterone and ADH secretion Decreases efferent arteriolar resistance and directly inhibits sodium reabsorption Results in natriuresis, diuresis, and decreased BP
39
ANP
Secreted by atrial BP increase Inhibits sodium and water reabsorption to reduce BP and volume Inhibits RAAS while increasing the GFR
40
Common secreted by the tubule
Bile salts Oxalate Urate Creatinine Catecholamines
41
Collecting duct
Concentrates the urine according to the ECF osmolality and ADH levels
42
Cockcroft-Gault Formula
GFR/CrCl = [(140-age)\*kg] / (72-SCr) Multiply by 0.85 for women
43
MDRD
Takes gender and race into account for eGFR Normal: \>60mL/min/1.73 m2
44
Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)
Measure creatinine w/ external filtration markers in order to provide a more accurate eGFR in patients w/ normal/mildly reduced GFR
45
BUN
Normal: 6-20 mg/dL Waste of protein breakdown - urea that becomes BUN as soon as its in the blood
46
Increased BUN DDx
Renal disease Excess protein breakdown High protein diet GI bleed
47
Decreased BUN DDx
Liver disease Starvation
48
Creatinine
Muscle breakdown byproduct Normal: 0.8-1.4 (men) 0.6-1.2 (women) Steady-state relationship w/ GFR Used w/ BUN to distinguished types of azotemia
49
Increased Creatinine DDx
Renal failure High protein diet Meds (ACEI, NSAIDs, diuretics) Muscular disease
50
Decreased Creatinine DDx
Pregnancy - normal effect 0.4-0.6 mg/dL Occurs because GFR and volume increase
51
Creatinine and BUN filtration dynamics
BUN can be absorbed over time w/ a decreased GFR Creatinine is not absorbed, is secreted into CT for excretion -Any Creatinine increase may be caused by blocked secretion (cimetidine (antacid, antihistamine), trimethoprim (Bactrim)
52
BUN:Creatinine increases
Both should increase proportionally to indicate intrinsic or post-renal disease
53
Increased BUN w/ normal creatinine DDx
Pre-renal azotemia Catabolic state (increased breakdown) GI bleed High protein diet Drugs (tetracyclines, steroids)
54
Decreased BUN:Creatinine DDx
ATN Low protein/starvation Liver disease Dialysis SIADH Pregnancy
55
Decreased BUN w/ Increased Creatinine DDx
Rhabdomyolysis Muscular patient in renal failure
56
Hyponatremia DDx and treatment
Volume overload Excess sodium and water loss Tx: sodium and water replacement, treat underlying cause
57
Hypernatremia DDx and Treatment
Excessive water loss -\> dehydration Tx: Fluid replacement w/ diuretics to eliminate excess sodium
58
Hypochloremia DDx
GI upset DKA Mineralocorticoid excess Salt-losing renal disease High bicarbonate levels
59
Calcium normal levels
8.5 - 10.5
60
Magnesium normal levels
1.4 - 2
61
Sodium normal levels
135-145 mmol/L
62
Potassium normal levels
3.5-5.5 mmol/L
63
Chloride normal levels
96 - 106
64
Phosphorus normal levels
2.0 - 4.5
65
Glucose normal levels
80-120 mg/dL
66
Hyperchloremia DDx
Metabolic acidosis GI loss Mineralocorticoid deficiency
67
Urine Chemical analysis
Glucose Bilirubin Ketones Specific gravity Blood pH Protein Urobilirubin Nitrite Leukocyte esterase
68
Specific gravity
Normal: 1.010-1.025 Indicates degree of urine concentration/dilution Low: Diabetes insipidus, tubular/renal damage, well-hydrated High: DM, adrenal insufficiency, hepatic disease, CHF, excessive water loss
69
Urine pH
Normal: ~6 Low: high protein diet, meds, DKA/metabolic acidosis High: Post-prandial, high veggie/dairy diet, meds, UTI (depends on organism)
70
Urine Protein
Single most important indicator of kidney disease Can also be benign - functional changes or orthostatic (adolescents)
71
Urine Glucose
Shows up when maximum threshold is reached (\>180) Investigate for diabetes May be benign - renal glycosuria from heavy meals or emotional stress
72
Urine Ketones
Fatty-acid metabolism Betahydroxybutyric acid most common DDx: DKA, restrictive carb diet/starvation
73
Urine Bilirubin
Indicates liver disease - Hepatocellular disease - Biliary obstruction - Increase in conjugated (direct) bili
74
Urine Urobilinogen
Converted from bilirubin in the intestinal tract Indicates liver problem, rules out bile duct obstruction if present DDx: hepatitis, cirrhosis, CHF, pernicious anemia
75
Urine blood
Hematuria (rbc intact): renal disease, infection, neoplasm, trauma Hemoglobinuria: same as hematuria + transfusion reaction, anemia, burns, poisoning
76
Urine Leukocyte esterase
Released into urine by neutrophilic granulocytes Indicates pyuria, bacteriuria, UTI
77
Urine Nitrate
Nitrate reduced by G(-) bacteria Indicates infection, usually E. coli
78
RBC casts
Indicates kidney is bleeding, either from vascular insult or parenchyma breakdown Acute inflammatory or vascular disorder May be only manifestation of acute glomerulonephritis
79
WBC casts
Indicate kidney inflammation/infection DDx: Acute pyelonephritis, interstitial nephritis, proliferative glomerulonephritis
80
Hyaline casts
Non-specific Get with concentrated urine or diuretic therapy
81
Granular casts
Leakage and aggregation of protein Coarse, deeply pigmented granular casts = ATN
82
Waxy casts
Last stage of granular cast degeneration Non-specific, any variety of acute or chronic kidney disease
83
KUB
Used to look for kidney stones Low radiation, inexpensive Not all stones show up
84
Sonography applications for kidney
Characterize renal mass Detect obstruction or hydronephrosis Polycystic kidney disease or renal failure (structural/functional abnormalities) Cannot see ureters
85
IVP indications
Really only used for obstruction or hematuria Medullary sponge kidney Papillary necrosis Stones in the ureter
86
CT scan
Gold standard for kidney stones and diagnosis renal tumors
87
Renal Arteriography
Gold standard for renal artery stenosis
88
Renal venography
Used to diagnose renal vein thrombosis
89
Retrograde/Anterograde Pyelography
For diagnosis of urinary tract obstruction or tumors CT and US are more commonly used
90
Hypovolemic hyponatremia DDx and Tx
GI or renal loss Tx: NS with a possible slow bolus and maintenance if ongoing loss
91
Normovolemic hyponatremia DDx
SIADH Primary polydipsia Low dietary sodium
92
Hypervolemic hyponatremia DDx and Tx
CHF Cirrhosis Kidney disease Nephrotic syndrome (rare) Tx: restrict fluids and sodium (1000-1200 mg/day) -Loop diuretics to removed excess fluid, watch potassium carefully
93
Hyponatremia and serum osmolality
Isotonic: Hyperproteinemia, hyperlipidemia Hypotonic: Determine volume status Hypertonic: Hyperglycemia, radiocontrast agents, Mannitol/Sorbitol/Glycerol/Maltose
94
Chronic Hyponatremia
Cerebral adaptation Sx: Fatigue, nausea, dizziness, confusion, lethargy, muscle cramps, gait issues, forgetfulness
95
Acute hyponatremia
Acute hyponatremic encephalopathy Cerebral effects depend on degree of hyponatremia Fatigue/malaise followed by HA, lethargy, coma, seizures Eventual respiratory arrest Causes permanent neurological damage or death
96
SIADH and treatment
Get volume depletion and decreased tissue perfusion Treat underlying cause, fluid restriction w/ oral salt tablets and loop diuretics if hypervolemic
97
Severe Hyponatremia Tx
@ high risk for brain herniation 3% hypertonic saline w/ hourly sodium checks - increase sodium by 4-6 mEq/L in 24 hours Cause osmotic demyelination if corrected too quickly, careful w/ high risk pts (acute post-op, hyperacute hyponatremia, or intracranial pathology)
98
Acute Hypernatremia
Rapid brain volume decrease causes cerebral brain rupture and cause intracerebral/subarachnoid brain hemorrhage Can occur with overly rapid correction of chronic hyponatremia = brain demyelination
99
Chronic Hypernatremia effects
Brain adapts w/in 1 day by pulling water from CNS and increasing cell solute uptake (increases water in cells) Most who get this already have an existing neurological disease that diminishes thirst
100
Hypernatremia Treatment
Free water (D5W) + NS if hypovolemic Decrease serum sodium slowly, monitor closely and calculate total body water replacement
101
Diabetes Indipidus
Central: not enough ADH produced -Tx: Desmopressin and fluid restriction Nephrogenic: kidneys are resistant to ADH -Tx: Thiazide and sodium restriction
102
Hypercalcemia
Cause: cancer, primary hyperparathyroidism, drugs (thiazide, lithium) EKG: Short QT interval Sx: N/V, polyuria/polydipsia, neuro or psych sx Causes oliguric renal failure, coma, V-arrhythmias, death
103
Hypercalcemia tx
NS and loop diuretics Drop 2-3 mL in 24-48 hrs Bisphosphonates (if malignant), Osteoclast inhibitors, dialysis
104
Hypocalcemia
Causes: Hypoparathyroidism, Vitamin D deficiency, loop diuretics, phosphates Sx: tetany, QT prolongation, mouth paresthesias, decreased myocardial contractility
105
Hypocalcemia Tx
Calcium salts IV over 5-10 minutes for less than 60 minutes -Use gluconate if in a peripheral vein Chronic hypocalcemia: Oral Ca supplements, 1-3 ELEMENTAL grams/day -Add 1000 Vitamin D if no response SE: Constipation, GI
106
Hyperphosphatemia
Decreased excretion w/ low GFR, chemo, rhabdo Can be chronic w/ hypocalcemia Tx: GI binders w/ IV Ca salts, dialysis and dietary restrictions -avoid aluminum-containing antacids (cause bone dx)
107
Hyperphosphatemia
Usually asx until \<1.0 Long-term: proximal muscle weakness and osteomalacia Tx: Severe - Slow IV phosphorus Mild/moderate - oral phosphates (250mg) SE: GI upset
108
Hypomagnesemia
Cause: Increased excretion, impaired absorption, or reduced intake, drugs (diuretics, aminoglycosides, ETOH) Sx: Neuromuscular (cramps, tetany), calcium metabolism inhibited EKG: Widened QRS, AF, VT, VF
109
Hypomagnesemia Tx
Only treat if symptomatic or \<1.0 IV MgSO4 - bolus and maintenance -SE: Flushing, sweating Oral tx if mild/moderate - sustained release -SE: Diarrhea
110
Hypermagnesemia
Sx worse as Mg increases - can cause cardiac or respiratory arrest Tx: IV calcium to antagonize neuro and CV effects - Renal failure: dialysis - Normal kidneys: forced diuresis w/ fluid and loop diuretics
111
Hypokalemia
Cause: beta-2 agonists, loop diuretics/thiazide, ACEI, PCN, ampho B, Insulin, metabolic acidosis, V/D EKG: U wave w/ inverted T waves
112
Hypokalemia Tx
Loop/thiazide-induced: 40-100 mEq potassium supplements PO Severe/sx: IV potassium in NS, dextrose to shift K into the cells -Monitor on EKG, have to give lower dose through a peripheral line
113
Hyperkalemia
Cause: increased intake, decreased excretion, Aldosterone resistance, shift to ECF Sx: Ascending muscle weakness EKG: Peaked T waves w/ shortened QT initially, progress to long QRS and QT with P wave loss -\> dysrhythmias
114
Hyperkalemia Tx
Stabilize cardiac w/ calcium gluconate IV D5W to shift potassium back into the cell Bicarb if acidotic Dialysis and K+ binders w/ renal failure Consider a loop diuretic
115
Hypotonic crystalloids
Lower osmotic pressure than blood Shift fluid into cells and interstitium D5W (once injected), 1/2 NS Dont use w/ suspected brain injury, liver disease, trauma, or burns
116
Hypertonic crystalloids
Volume expanders 7.5% NS, Dextrose, D50 Higher osmotic pressure - draw fluid into intravascular For severe hyponatremia, cerebral edema Cause fluid overload and pulmonary edema
117
Maintenance therapy
Daily weights to monitor Account for obligate fluid loss (1600) 0.45% NS + 20 mEq KCl For fever \>37, increase in 100-150 water needs 4/2/1 degree rule to calculate maintenance flow rate
118
Drugs that do not need adjusting for renal failure
Azithromycin Ceftriaxone Moxifloxacin Doxycycline
119
Replacement therapy treatment (hypovolemia)
Reduced intake/excess excretion - 0.45% then 0.25% if Na\>145, 0.9% if Na\<138 V/D - 0.9% until labs Hemorrhage/burn - 1-2 L wide bore IV, consider PRBC/Albumin Hydrate until urine production \>30 mL/hr occurs
120
Resuscitation (hypovolemic shock)
Severe - 1-2L 0.9% rapid infusion Mild/moderate - 50-100 L/hr then replace loss May cause fluid overload, be careful and look for signs
121
Colloids
Draw fluid into intravascular space Less volume required and longer duration of action than hypertonic crystalloids 5% Albumin Hydroxyethalstarches
122
5% Albumin
Volume expansion, protein replacement, hemodynamic stability in shock CI: Anemia, heart failure, sensitivity, ACEI w/in 24 hours (flushing, hypotension)
123
When to use D5W alone
Only if pt Na \>145 and symptomatic of hypernatremia
124
Uremia symptoms
Fishy breath odor Metallic taste in mouth Erectile dysfunction Retrosternal pain w/ inspiration Restless legs Numbness Cramps
125
CKD comorbidities/complications
Anemia Bone/mineral abnormalities CV and renal risk Diabetes
126
Dialysis indications
Hyperkalemia Metabolic acidosis Pericarditis
127
Pre-transplant immunosuppression
Steroids - 5mg/kg Mycophenolate mofetil - 500-1000 mg BID Basiliximab - 20mg 1 hour before transplant Gancyclovir and broad spectrum Abx prophylaxis
128
Transplant rejection diagnosis
Serial creatinine measurements \>20% over baseline Rule out non-immunologic causes
129
CKD vaccinations
H1N1 Hepatitis A and B Influenza Pneumococcal (PPV)
130
Criteria for a benign cyst
1. Echo free on US 2. Sharply demarcated 3. Enhanced back wall on US - fluid free of cells Follow up in 6 months if cyst is benign
131
Autosomal dominant polycystic kidney disease treatment
Treat HTN and manage infections -Bactrim, Chloramphenicol, Ciprofloxin Dialysis and transplant w/ ESRD Bilateral nephrectomy w/ recurrent UTIs
132
PKD history symptoms
Family history History of stones/UTIs/Pyelonephritis HTN Abdominal masses
133
Autosomal recessive polycystic kidney disease treatment
Manage HTN, UTIs - probably w/ constant Abx prophylaxis Diet supplements, growth hormone Dialysis/transplant
134
Acquired cystic kidney disease
Cysts in dialysis pts w/ CKD/ESRD Screen pts who have been on dialysis 3-4 yrs CT scan for Dx
135
Medullary cystic disorders
Occurs in kids - can't potty train, excessive thirst -low BP, failure to thrive Causes ESRD in childhood Tx: liberal fluid/sodium intake -manage renal failure, dialysis Transplant these kids
136
Medullary sponge kidney
Bunch of grapes/ bouquet of flower on CT/IVP Pts w/ kidney stones Renal failure doesn't occur Tx: manage UTIs and stone formation
137
When do you calculate the GFR
When Scr \> 1.5 or the pt is \>65 yo
138
Nephrotoxic agents
NSAIDs Aminoglycosides Heavy metals Radiocontrast agents Ethylene glycol (antifreeze, oxalic acid + Ca deposits throughout body)
139
Dosing modification guidelines
Need adjustments when GFR \< 10 or 10-50 Unless otherwise indicated, not needed when GFR \> 50